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S U P P L E M E N T
EPOS
3
2 0
2007
International
Rhinology
Rhinologie
Internationale
ABSTRACT
W.J. Fokkens, V.J. Lund, J. Mullol et al., European Position Paper on Nasal Polyps 2007.
Rhinology 45; suppl. 20: 1-139.
* corresponding author: Wytske Fokkens, Department of Otorhinolaryngology, Amsterdam Medical Centre, PO box 22660, 1100 DD Amsterdam,
The Netherlands. Email: w.j.fokkens@amc.nl
Rhinosinusitis is a significant and increasing health problem which results in a large financial burden on society. This evidence based
position paper describes what is known about rhinosinusitis and nasal polyps, offers evidence based recommendations on diagnosis
and treatment, and considers how we can make progress with research in this area.
Rhinitis and sinusitis usually coexist and are concurrent in most individuals; thus, the correct terminology is now rhinosinusitis.
Rhinosinusitis (including nasal polyps) is defined as inflammation of the nose and the paranasal sinuses characterised by two or more
symptoms, one of which should be either nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip),
facial pain/pressure, reduction or loss of smell; and either endoscopic signs of polyps and/or mucopurulent discharge primarily
from middle meatus and/or; oedema/mucosal obstruction primarily in middle meatus, and/or CT changes showing mucosal changes
within the ostiomeatal complex and/or sinuses.
The paper gives different definitions for epidemiology, first line and second line treatment and for research.
Furthermore the paper describes the anatomy and (patho)physiology, epidemiology and predisposing factors, inflammatory mechanisms, evidence based diagnosis, medical and surgical treatment in acute and chronic rhinosinusitis and nasal polyposis in adults and
children. Evidence based schemes for diagnosis and treatment are given for the first and second line clinicians. Moreover attention is
given to complications and socio-economic cost of chronic rhinosinusitis and nasal polyps. Last but not least the relation to the lower
airways is discussed.
Supplement 20
Participants:
Wytske Fokkens, Chair. Department of Otorhinolaryngology,
Amsterdam Medical Centre, Amsterdam
Valerie Lund, Co-Chair. Institute of Laryngology and
Otolaryngology. University College London, London
Joaquim Mullol, Co-Chair. Rhinology Unit & Smell Clinic, ENT
Department, Hospital Clnic IDIBAPS, Barcelona, Spain
Claus Bachert. Upper Airway Research Laboratory, Department
of Otorhinolaryngology, Ghent University, Belgium
Noam Cohen, Department of Otorhinolaryngology: Head and
Neck Surgery, University of Pennsylvania, Philadelphia, USA
Roxanna Cobo, Department of Otolaryngology, Centro
Mdico Imbanaco, Cali, Colombia
Martin Desrosiers, Department of Otolaryngology-Head and
Neck Surgery, University of Montreal, Montreal, Canada
Peter Hellings, Department of Otorhinolaryngology, University
Hospitals Leuven
Catholic University Leuven, Leuven, Belgium
Mats Holmstrom, Department of Otorhinolaryngology,
Uppsala University Hospital Uppsala, Sweden
Maija Hytnen, Department of Otorhinolaryngology, Helsinki
University Central Hospital, Helsinki, Finland
Nick Jones, Department of Otorhinolaryngology, Head and
Neck Surgery, Queen's Medical Centre, University of
Nottingham, Nottingham, UK
Livije Kalogjera, Department of Otorhinolaryngology/Head
and Neck Surgery, University Hospital "Sestre Milosrdnice",
Zagreb, Croatia
David Kennedy, Department of Otorhinolaryngology: Head and
Neck Surgery, University of Pennsylvania, Philadelphia, USA
Jean Michel Klossek, Department ENT and Head and neck
surgery, CHU Poitiers : Univ Poitiers Hopital Jean Bernard,
Poitiers, France
Introduction
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Diagnosis
Assessment of rhinosinusitis symptoms
Examination
Quality of Life
5-1
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5-3
5-4
5-5
7
7-1
7-2
7-3
7-4
7-5
Management
Treatment of rhinosinusitis with corticosteroids
Treatment of rhinosinusitis with antibiotics
Other medical management for rhinosinusitis
Evidence based surgery for rhinosinusitis
Influence of age concomitant diseases on sinus
surgery outcome
7-6 Complications of surgical treatment
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GLOSARRY TERMS
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References
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Supplement 20
1. Introduction
Rhinosinusitis is a significant health problem which seems to
mirror the increasing frequency of allergic rhinitis and which
results in a large financial burden on society (1-3). Data on
(chronic) rhinosinusitis are limited and the disease entity is
badly defined. Therefore, the available data are difficult to
interpret and extrapolate.
The last decade has seen the development of a number of
guidelines, consensus documents and position papers on the
epidemiology, diagnosis and treatment of rhinosinusitis and
nasal polyposis (4-7). In 2005 the first European Position Paper
on Rhinosinusitis and Nasal Polyps (EP3OS) was published (8, 9).
This first evidence based position paper was initiated by the
European Academy of Allergology and Clinical Immunology
(EAACI) to consider what was known about rhinosinusitis and
nasal polyps, to offer evidence-based recommendations on
diagnosis and treatment, and to consider how we can make
progress with research in this area. The paper has been
approved by the European Rhinologic Society.
Evidence-based medicine is an important method of preparing
guidelines (10, 11). Moreover, the implementation of guidelines is
equally important.
Table 1-1. Category of evidence (11)
Ia
Ib
IIa
IIb
III
IV
Since the preparation of the first EP3OS document an increasing amount of evidence on the pathophysiology, diagnosis and
treatment has been published (figure 1).
Figure 1. Randomized controlled trials in chronic rhinosinusitis with
or without nasal polyps. The number of trials in the last 5-6 years
equals the number ever published before.
Supplement 20
For epidemiological studies the definition is based on symptomatology without ENT examination or radiology.
2-2-1-1 Bacteria
Rhinosinusitis (including nasal polyps) is defined as:
inflammation of the nose and the paranasal sinuses characterised by two or more symptoms, one of which should be
either nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip):
- facial pain/pressure,
- reduction or loss of smell;
and either
endoscopic signs of:
- polyps and/or;
- mucopurulent discharge primarily from middle meatus
and/or; oedema/mucosal obstruction primarily in middle meatus,
and/or
CT changes:
- mucosal changes within the ostiomeatal complex and/or
sinuses.
Supplement 20
tional unit that comprises maxillary sinus ostia, anterior ethmoid cells and their ostia, ethmoid infundibulum, hiatus semilunaris and middle meatus. The key element is the maintenance of the ostial patency. An in depth discussion on factors
contributing to chronic rhinosinusitis and nasal polyps can be
found in chapter 4.
3-3 Chronic rhinosinusitis with or without nasal polyps
Chronic rhinosinusitis with or without nasal polyps is often
taken together as one disease entity, because it seems impossible to clearly differentiate both entities (22-24). Chronic rhinosinusitis with nasal polyps (CRS without NP) is considered a
subgroup of chronic rhinosinusitis (CRS) (fig. 3-1).
The question remains as to why ballooning of mucosa develops in polyposis patients and not in all rhinosinusitis patients.
Nasal polyps have a strong tendency to recur after surgery even
when aeration is improved (25). This may reflect a distinct property of the mucosa of polyp patients which has yet to be identified. Some studies have tried to divide chronic rhinosinusitis
and nasal polyps based on inflammatory markers (26-30) .
Although these studies point to a more pronounced eosinophilia and IL-5 expression in nasal polyps than that found in
patients with chronic rhinosinusitis, these studies also point to
a continuum in which differences might be found at the ends
of the spectrum but at the moment no clear cut division can be
made.
3-2 Rhinosinusitis
Rhinosinusitis is an inflammatory process involving the
mucosa of the nose and one or more sinuses. The mucosa of
the nose and sinuses form a continuum and thus more often
than not the mucous membranes of the sinus are involved in
diseases which are primarily caused by an inflammation of the
nasal mucosa. Chronic rhinosinusitis is a multifactorial disease
(15)
. Factors contributing can be mucociliairy impairment (16, 17),
(bacterial) infection (18), allergy (19), swelling of the mucosa for
another reason, or rarely physical obstructions caused by morphological/anatomical variations in the nasal cavity or
paranasal sinuses (20, 21). A role in the pathogenesis of rhinosinusitis is certainly played by the ostiomeatal complex, a func-
patients (33, 34). It had long been assumed that allergy predisposed to nasal polyps because the symptoms of watery rhinorrhoea and mucosal swelling are present in both diseases, and
eosinophils are abundant. However, epidemiological data provide no evidence for this relationship: polyps are found in 0.5
to 1.5% of patients with positive skin prick tests for common
allergens (34, 35).
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Supplement 20
11
results in the loss of cilia and ciliated cells, reaching a maximum around one week after the infection. Three weeks after
the beginning of the infection the number of cilia and ciliated
cells increases to nearly normal. However, as a sign of regeneration, immature short cilia (0.7 to 2.5 m in length) were often
seen (52). The impaired mucociliary function during viral rhinosinusitis results in an increased sensitivity to bacterial infection.
al. reported that whilst 39% of patients with CRS had asthma,
raised specific IgE or an eosinophilia, only 25% had true markers to show they were atopic (59). Finally, Emanuel et al. (60)
found relatively lower percentages of allergic patients in the
group of patients with the most severe sinus disease on CT
scan and Iwens et al. (61) reported that the prevalence and extent
of sinus mucosa involvement on CT was not determined by
the atopic state.
12
Supplement 20
which may be considered representative of the general population in Belgium, Gordts et al. (87) reported that 6% of subjects
suffered from chronic nasal discharge. A comparative study in
the north of Scotland and the Caribbean found that in ORL
clinics in both populations there was a similar prevalence of
CRS (9.6% and 9.3% respectively) (88). Not withstanding the
shortcomings of epidemiologic studies on CRS, it represents a
common disorder of multifactorial origin. A list of factors will
be discussed in the following chapter which are believed to be
etiologically linked to CRS.
4-5 Factors associated with chronic rhinosinusitis (CRS) without
nasal polyps
4-5-2 Allergy
Review articles on rhinosinusitis have suggested that atopy
predisposes to its development (54, 94). It is tempting to speculate
that allergic inflammation in the nose predisposes the atopic
individual to the development of CRS. Both conditions share
the same trend of increasing prevalence (95, 96) and are frequently
associated.
13
in populations with CRS. Benninger reported that 54% of outpatients with CRS had positive skin prick tests (103). Among
CRS patients undergoing sinus surgery, the prevalence of positive skin prick tests ranges from 50% to 84% (56, 60, 104), of which
the majority (60%) have multiple sensitivities (60). As far back as
1975, Friedman reported an incidence of atopy in 94% of
patients undergoing sphenoethmoidectomies (105).
However, the role of allergy in CRS is questioned by other epidemiologic studies showing no increase in the incidence of
infectious rhinosinusitis during the pollen season in pollensensitized patients (70). Taken together, epidemiologic data
show an increased prevalence of allergic rhinitis in patients
with CRS, but the role of allergy in CRS remains unclear.
Notwithstanding the lack of hard epidemiologic evidence for a
clear causal relationship between allergy and CRS, it is clear
that failure to address allergy as a contributing factor to CRS
diminishes the probability of success of a surgical intervention
(106)
. Among allergy patients undergoing immunotherapy, those
who felt most helped by immunotherapy were the subjects
with a history of recurrent rhinosinusitis, and about half of the
patients, who had had sinus surgery before, believed that the
surgery alone was not sufficient to completely resolve the
recurrent episodes of infection (106).
4-5-3 Asthma
Recent evidence suggests that allergic inflammation in the
upper and lower airways coexist and should be seen as a continuum of inflammation, with inflammation in one part of the
airway influencing its counterpart at a distance. The arguments
and consequences of this statement are summerized in the
ARIA document (107). Rhinosinusitis and asthma are also frequently associated in the same patients, but their inter-relationship is poorly understood. The evidence that treatment of
rhinosinusitis improves asthma symptoms and hence reduces
the need for medication to control asthma, mainly results from
research in children and will be discussed below (Chapter 9-7).
In short, improvements in both asthma symptoms and medication have been obtained after surgery for rhinosinusitis in children with both conditions (108-110).
Studies on radiographic abnormalities of the sinuses in asthmatic patients have shown a high prevalence of abnormal sinus
mucosa (111, 112). All patients with steroid-dependant asthma had
abnormal mucosal changes on CT compared to 88% with mild
to moderate asthma (113). Again caution should be exercised in
the interpretation of these studies. Radiographically detected
sinus abnormalities in sensitized patients may reflect inflammation related to the allergic state rather than to sinus infection.
4-5-4 Immunocompromised state
Among conditions associated with dysfunction of the immune
system, congenital immunodeficiencies manifest themselves
with symptoms early in life and will be dealt with in the paedi-
14
Supplement 20
4-5-8 Micro-organisms
4-5-8-1 Bacteria
Although it is often hypothesized that CRS evolves from ARS,
this has never been proven. Furthermore, the role of bacteria
in CRS is far from clear. A number of authors have described
the microbiology of the middle meatus and sinuses. However
if and which of these pathogen are contributory to the disease
remains a matter of debate. Bhattacharyya (2005) found that
both anaerobes and aerobic species could be recovered from
both diseased and the non-diseased contralateral side of
patients with chronic rhinosinusitis casting doubt on the aetiologic role of bacteria in CRS (141). Anaerobes are more prevalent
in infections secondary to dental problems.
Arouja isolated aerobes from 86% of the middle meatus samples
of CRS patients, whereas anaerobes were isolated in 8%. The
most frequent microorganisms were Staphylococcus aureus
(36%), coagulase-negative Staphylococcus (20%), and Streptococcus
pneumoniae (17%). Middle meatus and maxillary sinus cultures
presented the same pathogens in 80% of cases. In healthy individuals, coagulase-negative Staphylococcus (56%), S. aureus (39%),
and S. pneumoniae (9%) were the most frequent isolates. (142).
Some authors suggest that as chronicity develops, the aerobic
and facultative species are gradually replaced by anaerobes (143, 144).
This change may result from the selective pressure of antimicrobial agents that enable resistant organisms to survive and from
the development of conditions appropriate for anaerobic growth,
which include the reduction in oxygen tension and an increase
in acidity within the sinus. Often polymicrobial colonisation is
found; the contribution to the disease of the different pathogens
remains unclear. The presence of intracellular
S. aureus in epithelial cells of the nasal mucosa has been suggested to pay a significant risk factor for recurrent episodes of
rhinosinusitis due to persistent bacterial clonotypes, which
appear refractory to antimicrobial and surgical therapy (145).
4-5-8-2 Fungi
Fungi have been cultured from human sinuses (146). Their presence may be relatively benign, colonizing normal sinuses or
forming saprophytic crusts. They may also cause a range of
pathology, ranging from non-invasive fungus balls to invasive,
debilitating disease (147).
There is an increasing interest in the concept that the most
common form of sinus disease induced by fungus may be
caused by the inflammation stimulated by airborne fungal antigens. In 1999 it was proposed that most patients with CRS
exhibit eosinophilic infiltration and the presence of fungi by
histology or culture (148). This assertion was based on finding
positive fungal culture by using a new culture technique in 202
of 210 (96%) patients with CRS who prospectively were evaluated in a cohort study. No increase in type I sensitivity was found
in patients as compared with controls. The term eosinophilic
15
Pant et al. suggest that fungal-specific immunity is characterised by serum IgG3 and not IgE distinguished patients with
CRS and eosinophilic mucus from healthy controls, regardless
of whether fungi were found within the mucus. They found no
differences between those with CRS and the eosinophilic
mucus group and a group with allergic fungal rhinosinusitis (150).
Some authors suggest that non IgE mediated mechanisms to
fungal spores might be responsible for eosinophilic inflammation seen in some individuals (151) Shin et al. found that patients
with CRS had an exaggerated humoral and TH1 and TH2 cellular response to common airborne fungi, particularly
Alternaria. No increase in type I sensitivity was found in
patients as compared with controls (152). In another study no
correlation was found between fungal parameters and the clinical parameters of CRS or the presence of eosinophilia (153) and
the use of quantitative PCR produced a recovery rate of fungi
of 46% in a group with CRS and a control group (154).
A broad array of fungi has been identified in the sinus cavities
of patients with sinusitis through varied staining and culture
techniques (148, 149). As with the isolation of bacteria in sinus cavities in these patients, the presence of fungi does not prove that
these pathogens directly create or perpetuate disease. The use
of topical or systemic antifungal agents have not consistently
been shown to help patients with CRS (155, 156).
4-5-9 Osteitisthe role of bone
Areas of increased bone density and irregular bony thickening
are frequently seen on CT in areas of chronic inflammation
and may be a marker of the chronic inflammatory process (157).
However, the effect during the initial phases of a severe CRS
frequently appears as rarefaction of the bony ethmoid partitions. Although to date bacterial organisms have not been
identified in the bone in either humans or animal models of
CRS, it has been suggested that that this irregular bony thickening is a sign of inflammation of the bone which in turn
might maintain mucosal inflammation (158).
In rabbit studies it was demonstrated that not only the bone
adjacent to the involved maxillary sinus become involved, but
that the inflammation typically spreads through the Haversian
canals and may result in bone changes consistent with some
degree of chronic osteomyelitis at a distance from the primary
infection (159, 160) It is certainly possible that these changes, if further confirmed in patients, may at least in part, explain why
CRS is relatively resistant to therapy.
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Supplement 20
17
polyps
Although the mechanisms involved in the pathogenesis of
nasal polyps (NP) remain largely unclear, there are reports suggesting an underlying genetic predisposition. This concept is
supported by some clinical data and genetic studies. This chapter does not include NP in cystic fibrosis (CF), which is known
to be a hereditary disease with multi-systemic involvement
with genetic variations, presenting with defect in chloride
transport across membranes and dehydrated secretions.
18
Supplement 20
included group
100 healthy children
from birth to maturity
examination method
ENT-examination
and pa-Xray of sinuses
result
30% pathologic antra overall
>50% pathologic antra with
previous upper airway infection
(URTI) in the last two weeks
one or more URTI in
the year:
0-2 years: 84%
4-6 years: 74%
> 7 years: 80%
conclusion
high rate of pathology, can be
under or over estimated because
of the examination technique
increased between
November and February
19
mucosa and the sinus fluid (240). Epithelial cells are the first barrier in contact with virus or bacteria. These release and express
several mediators and receptors to initiate different viral elimination mechanisms Recently evidence of biofilms has been
suggested in experimentally-induced bacterial (pseudomonas)
sinusitis in rabbits (241).
5-2-1-1 Epithelial cells
No specific studies are available concerning the role of epithelial cells in ARS. In cases of experimental induced viral rhinosinusitis, epithelial damage is observed. In vitro release of Il-6
after rhinovirus innoculation has been found (242). Epithelial
cells in contact with human rhinovirus express intracellular
adhesion molecule 1 (ICAM-1) which belongs to the
immunoglobulin supergene family. Membranous (m-ICAM)
and circulating (s-ICAM) forms are detected during common
colds and expressed in vitro by epithelial cells (243).
5-2-1-2 Granulocytes
Neutrophils are responsible for proteolytic degradation due to
the action of protease (244). In vitro leucocytes produce lactic
acid during S. pneumoniae induced rhinosinusitis (245) .
Neutrophils are a likely source of IL-8 and TNF- (246).
5-2-1-3 T lymphocytes
These are stimulated during ARS by pro-inflammatory
cytokines such as IL-1, IL-6 and TNF- (247).
Experimentally, antigen stimulated TH2 seems active in the
augmented response to bacterial with S. pneumoniae in allergic mice (236).
5-2-1-4 Cytokines
Mucosal tissue sampled from the maxillary sinus in ARS
(n=10), demonstrated significantly elevated IL-8 concentrations compared to 7 controls (240). IL-8 belongs to the CXCchemokine group and is a potent neutrophil chemotactic protein, which is constantly synthesized in the nasal mucosa (247).
Similar results, though not reaching significance, were
obtained for IL-1 and IL-6, whereas other cytokines such as
GM-CSF, IL-5 and IL-4 were not upregulated. Another study
confirm that some specific cytokines were more implicated in
ARS (IL-12, IL-4, IL-10, IL-13) (248). Recently, IL-8, TNF-alpha
and total protein content were increased in nasal lavage from
subjects with ARS compared to controls and allergic rhinitis
subjects (246). The cytokine pattern found in ARS resembles
that in lavage from naturally acquired viral rhinitis (249).
20
Supplement 20
5-3-1-1 Lymphocytes
T cells, in particular CD4+ T helper cells, participate in the
CRS pathophysiology by being predominant at the initiation
and regulation of inflammation. (257). Epithelial cells from CRS
express functional B7 co-stimulatory molecules (B7-H1, B7H2, B7-H3, and B7-DC) and may contribute in the regulation
of lymphocytic activity at mucosal surfaces (258).
5-3-1-2 Eosinophils
Tissue eosinophilia in CRS has been widely reported as a marker
of inflammation (259), and also shows some relationship to severity
(260)
and prognosis (261). CRS is also accompanied by 3-nitrotyrosine
formation, largely restricted to the eosinophils (262) while Br-Tyr, a
molecular footprint predominantly formed by eosinophil peroxidase-catalyzed tissue damage, may serve as an objective index of
sinus disease activity when compared to healthy mucosa (263).
However, biopsies from paediatric CRS patients show less
eosinophilic inflammation, basement membrane thickening, and
mucous gland hyperplasia than in adults, see section 9 (264).
The association between eosinophil inflammation and the
presence of fungi in CRS has recently been a matter of considerable interest and investigation (148, 149). Eosinophil infiltration
on mucus cytology is correlated with the clinical diagnosis, the
presence of fungal elements on cytology, and serum IgE (265).
No significant correlations between the fungal culture, middle
meatal eosinophilia and clinical parameters of CRS were found
(266)
. In addition, a chronic eosinophilic inflammatory response
to Aspergillus fumigatus is also evoked in a murine model of
CRS, mimicking the human eosinophilic disease (267).
CRS has lower levels of eosinophilic markers [eosinophils,
eotaxin, and eosinophil cationic protein (ECP)] compared with
nasal polyps (268, 269), while round cell infiltration, eosinophils and
plasma cells also differ in CRS and nasal polyp patients (270). All
tissue/patients
cells
mediators
technique
conclusions
no
ELISA
B cells
T cells
no
histology
IL-6, IL-8,ICAM-1
ELISA
Passariello 2002
(239)
Yu 2004 (236)
eosinophils,
polymorphonuclear cells
infection with
pseudomonas
T lymphocyte
eosinophil
histology
IHC
no
electronic
microscopy
nasal lavage
bacterials counts
21
these findings suggest that CRS without and with nasal polyps
might be two different disease entities, although they may also
be interpreted as different degrees of inflammation.
5-3-1-5 Neutrophils
In one study, tissue infiltration in CRS was dominated by lymphocytes and neutrophils (274). In another study, eosinophils
dominated in the middle meatal lavages of asthma patients
while neutrophils dominate in the nasal cytology of patients
with small airway disease. Their correlation with lung function
suggests an involvement of the lower airways in CRS (266).
tissue/patients
sinonasal mucosa (CRS)
healthy nasal mucosa
sinonasal mucosa (CRS
without NP and wNP)
sinonasal mucosa
(CRS children & adults)
nasal secretions (CRS patients)
sinonasal mucosa (CRS)
cell type
eosinophils
technique
IHC
conclusions
CRS: increase of eosinophil activation
macrophages
RT-PCR
eosinophils
lymphocytes
mast cells
healthy turbinate
histology
neutrophils
nasalepithelial
primary cells
eosinophils, mast cells,
macrophages, B cells,
T cells
neutrophils
uniCAP system
T lymphocytes
IHC
IHC
IHC
nasal cytology
IHC:immunohistochemistry; RT-PCR: reverse-transcriptase protein chain reaction; ELISA: enzyme-linked immunosorbent assay; CRS without NP:
chronic rhinosinusitis without nasal polyps; CRS with NP: chronic rhinosinusitis with nasal polyps; H&E: hematoxilin & eosin; GMS: Giemsa)
22
5-3-2-1 Cytokines
IL-8, a highly potent chemoattractant for neutrophils, has been
demonstrated in chronic rhinosinusitis tissue (282) and IL-8 protein concentrations in nasal discharge from chronic rhinosinusitis patients were significantly higher than in allergic rhinitis
patients in a study also involving immunohistochemistry and in
situ hybridization (283). In a study measuring cytokine protein
concentrations including IL-3, IL-4, IL-5, IL-8 and GM-CSF in
tissue homogenates, IL-8 was found to be significantly increased
in ARS, and IL-3 in chronic rhinosinusitis mucosa compared to
inferior turbinate samples (278). IL-3 might be involved in the
local defense and repair of chronically inflamed sinus mucosa by
supporting various cell populations and indirectly contributing
to fibrosis and thickening of the mucosa (284).
In patients with CRS, IL-5, IL-6, and IL-8, and expression in
nasal mucosa is elevated in comparison with healthy
subjects(285). Reports of different types and quantities of inflammatory mediators also support the hypothesis that CRS and
nasal polyps may constitute two different disease entities.
Albumin and IL-5 levels, but not IL-8, are lower in patient with
CRS without than with nasal polyps (286). CRS without nasal
polyps is characterized by a Th1 polarization with high levels of
IFN- and TGF-, while CRS with nasal polyps shows a Th2
polarization with increased IL-5 and IgE concentrations (269).
By assessing biomarker profiles of disease, lower levels of IgE
and IL-5 were found in CRS than in nasal polyps (248). While no
differences were found in IL-6, IL-8, and IL-11, TGF- was
found to be 3 times greater in patients with nasal polyps, as
well as responding more to IL-4, than in patients with CRS
alone (287). Levels of IL-5 and ECP were lower in CRS than in
nasal polyps, and correlated directly with peptide-LTs and
inversely with PGE2 (288).
Patients with CRS show exaggerated humoral and cellular
responses, both of Th1 and Th2 (IL-5, IL-13) types, to common
airborne fungi, particularly Alternaria (152). Using the YAMIK
sinus catheter, both saline or betamethasone decreased IL-1
and IL-8 levels after the 2nd and 3rd weeks of therapy in CRS
patients while TNF- level decreased only in patients treated
with betamethasone (289). Besides the improvement of CRS
symptoms and amelioration of asthma, elevated serum Th2
cytokines (IL-4 and IL-5) were normalized after sinus surgery
(290)
. Staphylococcus aureus exotoxin B increased IL-6 levels in
nasal epithelial cell from patients with CRS (291).
Toll-like receptors (TLR) and the alternate pathway of complement are important components of innate immunity that are
expressed in human sinonasal epithelium. Detectable levels of
TLR mRNA were found in human sinonasal tissue from CRS
patients (292).
An increased expression of TLR2 and proinflammatory
cytokines (RANTES and GM-CSF) was also found in CRS
patients compared with controls (293).
5-3-2-2 Chemokines
In patients with CRS, chemokines have a different expression
Supplement 20
23
5-3-2-6 Immunoglobulin
IgE+ cell numbers are raised in patients with allergic, fungal,
and eosinophilic CRS when compared with controls (273). In a
clinical trial, preoperative total IgE levels showed a significant
correlation with the extent of disease on sinus CT, without any
change one year after sinus surgery (308). IgG antibodies to
Table 5-3. Inflammatory mediatos (cytokines, chemokines, toll-like receptors, adhesion molecules, eicosanoids, and matrix metalloproteinases) in
chronic rhinosinusitis without nasal polyps
author, year
Ruback, 2004 (276)
tissue, patient
sinonasal mucosa (biopsies)
marker
IL-5, IL-8
technique
ELISA
conclusion
CRS without NP: lower levels of IL-5 but
not IL-8 than in NP
ELISA
sinonasal mucosa
toll-like receptors
(TLR)
RT-PCR
TGF-1, NFkB
IHC
TGF-1
IHC
MMP-9, TGF-1
IHC
TGF-
RT-PCR
Elhini,2005 (294)
CCR4+, CCR5+
IHC
Real Time PCR
TGF- than in NP
CRS patients: increase of CCR4+ in atopics
and decrease of CCR5+ in non-atopics
ELISA
IL-5
ELISA
nasal secretions
15 cytokines (IL-5)
ELISA
L-selectin ligands
IHC
IL-6
ELISA
sinonasal mucosa
TLR2, RANTES,
GM-CSF
CCL 20
IL-4, IL-5
IHC
Real Time PCR
ELISA
sinonasal mucosa
sinonasal mucosa
nasal mucosa
CysLT receptors
EP Receptors
MMP-9
HPLC +
bioassay
real time PCR
ELISA
real time PCR
MMP-7, MMP-9,
TGF-1 compared to NP
TIMP-1, TGF-1
Van Zele, 2006 (307)
sinonasal mucosa
sinonasal mucosa
INF-, TGF-
IHC
ELISA
ELISA
UniCAP system
IL-5, IL-6, IL-8, NFkB ELISA
RT-PCR
FESS: functional endoscopic sinus surgery; Immunohistochemistry: CRS without NP: chronic rhinosinusitis without nasal polyps, CRS with
NP:chronic rhinosinusitis with nasal polyps; RT-PCR: reverse-transcriptase protein chain reaction; ELISA: enzymo-linked immunosorbent assay
24
Supplement 20
Table 5-4. Inflammatory mediators (immunoglubulins, nitric oxide, neuropeptides, mucins, and others) in Chronic Rhinosinusitis without nasal polyps
author, year
Kim, 2004 (314)
tissue, patient
maxillary sinonasal mucosa
sinonasal mucosa
marker
MUC5AC, MUC5B
technique
RT-PCR
conclusion
increased in CRS compared to healthy
controls
MUC8
RT-PCR
MUC8 is upregulated in CRS compared to
controls
nasal NO
chemi-luminenNO during humming is a reliable marker
scence
of sinus patency
fungal IgG
UniCAP system IgG is increased in CRS compared to
healthy controls
TLR4, iNOS
in-situ
TLR4 and iNOS are increased in CRS
hybridization
compared to healthy controls
MUC5AC, MUC2
ELISA
increase of MUC5AC and decrease of
MUC2 in CRS
fungal IgG, IgA
ELISA
IgG3 and IgA are increased in CRS
VEGF
ELISA
VEGF expression is higher in the sinus
mucosa than in nasal mucosa and serum
VIP, CGRP
radioimmunoneuropetides are increased in acute attacks
assay
IgE+ cells
immunoIgE+ cells are increased in CRS compared
histochemistry
to healthy controls
total IgE
ELISA
correlation of IgE levels with the CRS extent
MUC1, MUC2, MUC4 IHC
MUC5AC, MUC5B
In situ
there exist different MUC expression
hybridization
patterns depending on the sinonasal disease
MUC5AC
IHC
MUC5AC is expressed in the epithelium
but not in submucosal glands
nasal NO
chemimedial and surgical treatments increase
luminescence
nNO, with correlation with nasal symptoms
MUC5AC, MUC5B
ELISA
increased in CRS compared to healthy
controls
VEGF
IHC
CRS without NP: lower expression of
VGEF compared to NP
surfactant protein-A
RT-PCR
increased expression of SP-A in CRS
compared to healthy controls
FESS: functional endoscopc sinus surgery; IHC:immunohistochemistry; CRS without NP:chronic rhinosinusitis without nasal polyps; CRS with
NP:chronic rhinosinusitis with nasal polyps; RT-PCR: reverse-transcriptase protein chain reaction; ELISA: enzymo-linked immunosorbent assay
25
population
Adults with CRS (n=16) Biopsies of mucosa
(241)
Ramadan, (333)
Sanclement, (334)
Bendouah, 2006 (335)
Bendouah, 2006 (336)
Sanderson, (337)
Zuliani, (338)
Biofilm not seen in sinusitis model with bacteria defective with type
IV pili (impaired attachement). Increased CBF seen in response.
All clinically had sinusitis. 21 cultured P.aeruginosa. Morphological
evidence of biofilm seen in all on SEM No biofilm seen in the 22
contraleteral controls
Adults with CRS (n=5) SEM of Mucosal biopsies All 5 had morphological evidence of biofilms based on SEM
Adults with CRS (n=30) controls (n=4)
Morphological evidence of biofilms seen in 24 patients. No controls
SEM/TEM of mucosal biopsies
positive.
Adults with CRS (n=19)
22 of 31 isolates of S. Aureus, Coagulase negative Staphylococcal
Semi quantitative in vitro culture assessment
Species, P. aeruginosa demonstrated biofilm forming capacity in vitro
Adults with CRS (n=19) Semi quantitative in vitro Correlates above data with a dichotomous outcome of poor or
culture assessment
favourable based on symptoms and endoscopic signs.
Poor outcome overrepresented in patients with biofilm forming
isolates
Adults with CRS (n=18) controls (n=5)
FISH for S. pneumoniae, S. aureus, H. influenza and P. aeruginosa
FISH visualised with confocal microscopy of
and standard cultures
mucosal biopsies
14 of 18 had evidence of biofilm and 2 of 5 controls.
Cultures did not correlate.
Children with CRS and OSA (n=16 )
All 8 CRS patients had biofilms in the adenoids. No control
Adenoid samples
demonstrated significant biofilm coverage.
FESS: functional endoscopic sinus surgery; SEM:scanning electron microscopy; TEM:transmission electron microscopy; OSA:obstructibe sleep
apnoea FISH:fluorescent in situ hybridisation
26
Supplement 20
a significantly higher number of plasma cells (CD138) was present in NP versus controls and CRS without polyps (269, 346). This
fact is reflected by a significant increase in immunoglobulin A,
G and E synthesis (van Zele, unpublished).
S. aureus superantigens (SAgs) bind the V beta-region of the
T-cell receptor (TCR) outside the peptide-binding site.
Approximately 50 distinct V beta-domains exist in the human
repertoire, and distinct SAgs will bind only particular domains,
generating a pattern of V beta-enrichment in lymphocytes
dependent on the binding characteristics of a given toxin. Flow
cytometry was used to analyze the V beta-repertoire of polypderived CD4+ and CD8+ lymphocytes in the light of the
known skewing associated with SAg exposure. Seven of 20
subjects exhibited skewing in V beta-domains with strong associations to S. aureus SAgs. This study establishes evidence of
S. aureus SAg-T-cell interactions in polyp lymphocytes of 35%
of CRS with NP patients (347).
5-4-1-2 Eosinophils
An increased number of eosinophils, demonstrated by HE staining or EG2 IHC, is a hallmark of Caucasian NPs. Eosinophil
numbers are significantly higher in NP tissue compared to CRS
(348)
and other sinus disease and control mucosa, and are further
increased in patients with co-morbid asthma and/or aspirin sensitivity, but independent from atopy (192, 349). In a study evaluating
the percentage of eosinophils (out of 1000 inflammatory cells
counted per vision field), 31 patients with untreated chronic
sinusitis without nasal polyps all had less than 10% eosinophils
(overall mean 2%), whereas in 123 untreated nasal polyp specimen, 108 samples showed more than 10% eosinophils (overall
mean 50%) (350). Generally, the differences in ECP measurement
between diseases are more pronounced than the cell numbers,
indicating a more intense activation of eosinophils in polyps.
However, the eosinophilic inflammation in nasal polyp tissue
from China, as measured by ECP and cytokine/chemokine levels (IL-5, eotaxin), was not significantly different from control
tissue, and was significantly lower compared to Caucasian
polyps. The semi-quantitative scores for EG2+ eosinophils were
0,45+1.15 for the Chinese polyp patients and 1,95 2,85 for the
Caucasian polyp patients, being significantly different (346).
Furthermore, eosinophil numbers are not different from controls and cystic fibrosis polyps (269).
5-4-1-3 Macrophages and dendritic cells
Macrophage numbers seem to be slightly increased in nasal
polyps, and these cells express increased amounts of
macrophage mannose receptors (MMR), an innate pattern recognizing receptor, capable of phagocytosis of invaders and signal transduction for proinflammatory mechanisms (275). There
also is a higher number of macrophages in patients with CF
than in patients with CRS or in controls (351). Our knowledge on
dendritic cells is very limited; they are present in nasal polyps,
and express the high affinity IgE receptor (344, 352).
Table 5-6. Inflammatory cells in Chronic Rhinosinusitis with nasal polyps (IHC; immunohistochemistry; RT-PCR; reverse-transcriptase protein
chain reaction; ELISA: enzymo-linked immunosorbent assay)
author, year
Fokkens, 1990
cell type
T lymphocytes
B lymphocytes
eosinophils
neutrophils
dendritic cells
Ig+ cells
eosinophils
technique
IHC
conclusion
IHC
mast cells
IHC
nasal polyps
healthy nasal mucosa
nasal polyps
dendritic cell
IHC
endothelial cells
flow cytometry
RT-PCR
nasal polyps
healthy nasal mucosa
nasal polyps
mast cells
fluorescence
microscopy
ELISA
RT-PCR
neutrophils
IHC
endothelial cells
IHC
epithelial cells
ELISA
epithelial cells
IHC
RT-PCR
nasal polyps
sinonasal mucosa (CRS)
healthy nasal mucosa
nasal polyps
macrophages
real-time
RT-PCR
epithelial cells
IHC
nasal polyps
healthy nasal mucosa
endothelial cells
IHC
nasal polyps
nasal polyps
antrochoanal polyp
nasal polyps
healthy nasal mucosa
nasal polyps
sinonasal mucosa (CRS)
healthy nasal mucosa
nasal polyps
sinonasal mucosa (CRS)
healthy nasal mucosa
ELISA
RT-PCR
flow cytometry
epithelial cells
IHC
ELISA
T lymphocytes
plasma cells
eosinophils
neutrophils
IHC
epithelial cells
flow cytometry
RT-PCR
(344)
Jankowski, 1996
(350)
(359)
Chen, 2004
(364)
Claeys, 2004
(271)
Hao, 2006
(345)
Schaefer, 2006
(357)
tissue, patients
nasal polyps
healthy nasal mucosa
allergic rhinitis nasal mucosa
nasal polyps
sinonasal mucosa (CRS)
nasal polyps
inferior turbinate
nasal polyps
healthy nasal mucosa
epithelial cells
IHC
28
Supplement 20
29
30
patients with aspirin intolerance, suggesting a specific regulation in this subgroup (297).
Summarizing, eicosanoid changes in paranasal sinus diseases
are generally characterized by an up- regulation of CysLTs,
LXA4 and PGD2 and a down- regulation of COX-2 and PGE2.
Eosinophilic markers such as ECP and IL-5 correlate directly
with LTC4/D4/E4 and inversely with PGE2 concentrations,
demonstrating the close relationship to severity of inflammation. In the sinus mucosa of aspirin intolerant subjects, these
changes might be extreme, as the degree of inflammation is
maximal, and the clinically apparent aspirin intolerance triad
may be dependent on severe inflammation in the airways. In
contrast, specific changes such as a relative down-regulation of
lipoxin LXA4 in those patients is less obvious, as they possibly
only unfold under the pre-condition of severe inflammation.
5-4-2-5 Metalloproteinases and TGF-
The expression of TGF-1 and TGF-2, predominantly by
eosinophils, and their putative effects on fibroblast activity and
pathogenesis of nasal polyps have been suggested in several
studies (222-224). These studies compared protein levels in tissue
homogenates from patients with nasal polyps who were either
untreated or treated with oral corticosteroid, and control subjects. Patients with untreated polyp samples and controls
showed significantly higher concentrations of IL-5, eotaxin,
ECP and albumin, and significantly lower concentrations of
TGF-?1. In contrast, corticosteroid treatment significantly
reduced IL-5, ECP and albumin concentrations, whereas TGF1 was increased (205).
These observations suggest that IL-5 and TGF-1 represent
cytokines with counteracting activities, with a low TGF-1 protein concentration in IL-5 driven nasal polyps. Furthermore,
they support the deposition of albumin and other plasma proteins as a possible pathogenic principle of polyp formation,
caused by the lack of upregulation/production of TGF-1. The
lack of TGF also may prevent the upregulation of TIMPs, thus
failing to prevent ECM breakdown by metallo-proteinases. The
relative down-regulation of ECM is especially apparent in comparison to CRS, demonstrating a significantly increased TGF
versus controls (269).
TGF-1 is a potent fibrogenic cytokine that stimulates extracellular matrix formation, acts as a chemoattractant for fibroblasts,
but inhibits the synthesis of IL-5 and abrogates the survival-prolonging effect of haematopoietins (IL-5 and GM-CSF) on
eosinophils (225). Staphylococcal enterotoxins may induce a further
down-regulation of TGF in specific populations of patients (346).
Oedema and pseudocyst formation characterize NP, with a few
areas of fibrosis. An imbalance of metallo-proteinases with an
upregulation of MMP-7 and MMP-9, but not TIMP-1, in nasal
polyps has been recently demonstrated (408). This results in the
enhancement of MMP-9 in NP, which may account for oedema formation with albumin retention. The therapeutic effect
of macrolide antibiotics may partially be related to the suppression of MMPs in the airways (409).
Supplement 20
Table 5-7. Inflammatory mediatos (cytokines, chemokines, adhesion molecules, eicosanoids, and matrix metalloproteinases) in Chronic Rhinosinusitis
without nasal polyps (IHC: immunohistochemistry; RT-PCR: reverse-transcriptase protein chain reaction; ELISA: enzymo-linked immunosorbent
assay; CRS; chronic rhinosinusitis without nasal polyps; NP: chronic rhinosinusitis with nasal polyps; FESS: functional ensodcopic sinus surgery)
author, year
Camilos, 1993
(99)
tissue, patient
nasal polyps
sinonasal mucosa (biopsies)
nasal polyps
sinonasal mucosa
marker
GM-CSF, IL-3
technique
IHC
GM-CSF
IHC
conclusion
cellular sources of GM-CSF and IL-3 in NP
remain to be determined
eosinophil infiltration into the respiratory
mucosa (allergic reaction, CRS with nasal
polyps) is modulated by epithelial cell GMCSF
nasal polyps
sinonasal mucosa
RT-PCR
nasal polyps
sinonasal mucosat
CC-chemokines
eotaxin, RANTES
and MCP-3
ELISA
nasal polyps
sinonasal mucosa
TNF-, GM-CSF,
IL-1RA, RANTES,
be produced by eosinophils.
GRO-
IL-4, IL-5, IFN-
mRNA
RT-PCR
Southern blot
nasal polyps
healthy sinonasal mucosa
allergic rhinitis mucosa
nasal polyps
IL-5
nasal polyps
ELISA
RT-PCR
Elispot
nasal polyps
sinonasal mucosa
nasal polyps
sinonasal mucosa
Soluble IL-5R
RT-PCR
TGF-1, NFkB
IHC
Watelet, 2004a
MMP-9, TGF-1
IHC
ELISA
TGF-1
IHC
(303)
CCR4+, CCR5+
MMP-7, MMP-9,
ELISA
IHC
real time PCR
ELISA
sinonasal mucosa
TIMP-1, TGF-1
COX-2
PGE2
L-selectin ligands
sinonasal mucosa
nasal polyps
turbinate mucosa
nasal mucosa
eotaxin, eotaxin-2,
and -3
CysLT receptors
EP Receptors
IHC
real time PCRS
ELISA
real time PCR
sinonasal mucosa
TLR2, RANTES,
GM-CSF
CCL-20
32
Supplement 18
33
Not only activated eosinophils but also mast cells are abundant
in the nasal polyps tissue from ASA-sensitive patients (355, 446).
The density of mast cells was correlated with the number of
polypectomies, implicating an important role for these cells in
the pathogenesis of CRS with nasal polyps. Stem cell factor
(SCF) also called c-kit ligand is a multi-potent cytokine generated by nasal polyp epithelial cells and critical for differentiation, survival, chemotaxis and activation and of human mast
cells but also involved in eosinophil activation and degranulation. SCF expression in nasal polyp epithelial cells in culture
correlated closely with the density of mast cells in nasal polyp
tissue and was significantly higher in asthmatic patients with
aspirin hypersensitivity as compared to aspirin tolerant patients
(355)
.
5-5-3-2 Arachidonic acid metabolites
Since Szczeklik et al (447) reported an increased susceptibility of
nasal polyps cells from ASA-sensitive patients to the inhibitory
action of aspirin, arachidonic aid metabolism abnormalities
have been considered a distinctive feature of nasal polyps in
this subpopulation of patients. A significantly lower generation
of PGE2 by nasal polyps and, nasal polyp epithelial cells as
well as a decreased expression of COX-2 in nasal polyps of
these patients were reported (398, 448). Low expression of COX-2
mRNA in nasal polyps from ASA-sensitive patients was in turn
linked to a downregulation of NF-B activity and to abnormal
regulation of COX-2 expression mechanisms at the transcriptional level (449, 450). Since PGE2 has significant anti-inflammatory
activity, including inhibitory effect on eosinophil chemotaxis
and activation, it has been speculated that an intrinsic defect in
local generation of PGE2 could contribute to development of
more severe eosinophilic inflammation in aspirin-sensitive
patients. Although a significant deficit of PGE2 was demonstrated in polyp tissue of ASA-sensitive as compared to ASAtolerant patients, decreased expression of COX-2mRNA and
PGE production seem to be a feature of CRS with nasal polyps
also in patients without ASA-sensitivity representing more
general mechanism involved in the growth of nasal polyps. On
the other hand the percentages of neutrophils, mast cells,
eosinophils, and T cells expressing prostaglandin EP2, but not
EP1, EP3, or inflammation in ASA-sensitive patients and some
studies demonstrated an increased production of cysteinyl
leukotrienes in nasal polyps of ASA-sensitive asthmatics as
compared to aspirin tolerant patients in vitro (400, 451) but these
observations could not be reproduced in vivo when nasal
washes were analysed (388, 452). Similarly when nasal polyp dispersed cells were cultured basal and stimulated release of
LTC4 was found to be similar in nasal polyp cells from from
ASA-sensitive and ASA-tolerant patients (355). Whole blood
cells from aspirin sensitive and tolerant patients did not differ
in their ability to generate cyclooygenase and lipoxygenase
34
Supplement 20
tolerant patients aspirin triggers 15-HETE generation, suggesting the presence of a specific abnormality of 15-LO pathway in
these patients (448). Upregulation of 15-lipoxygenase and
decreased production of the anti-inflammatory 15-LO metabolite lipoxin A4 found in nasal polyp tissue from ASA-sensitive
patients further points to a distinctive but not yet understood
role for 15-LO metabolites in nasal polyps (288).
5-6 Conclusion
Although far from being completely understood, pathomechanisms in ARS, CRS and NP are better understood today and
begin to allow us to differentiate these diseases via their
cytokine profile, their pattern of inflammation as well as
remodeling processes.
35
6. Diagnosis
6-1 Assessment of rhinosinusitis symptoms
36
Supplement 20
ations in the olfactory mucosa due to the disease or its treatment eg repeated nasal surgery.
Subjective scoring of olfaction is a commonly used assessment
method. In validating clinical settings, subjective scores have
been found to correlate significantly to objective olfactory
threshold and qualitative tests in normal population, rhinosinusitis and other disease conditions (477-480) as well as numerous
clinical studies concerning other diseases than rhinosinusitis
(Evidence level Ib).
6-1-3-4 Facial pain and pressure
Facial or dental pain, especially unilateral, have been found to
be predictors of acute maxillary sinusitis with fluid retention in
patients with a suspicion of infection, when validated by maxillary antral aspiration (455) or paranasal sinus radiographs (481). The
importance of facial pain as a cardinal sign of chronic rhinosinusitis has also been called into question (482) where the symptoms are more diffuse and fluctuate rendering the clinical correlation of facial pain and pressure scorings against objective
assessments unconvincing. Poor correlation between facial
pain localisation and the affected paranasal sinus CT pathology
in patients with supposed infection, both acute and chronic,
has been reported (483). However, rhinosinusitis disease specific
quality of life studies also include facial pain-related parameters, which have been validated (465).
6-1-3-5 Overall rating of rhinosinusitis severity
Overall rating of rhinosinusitis severity can be obtained as such
or by total symptoms scores, which are summed scores of the
individual symptoms scores. These are both commonly used,
but according to an old validation study for measuring the
severity of rhinitis, scores indicating the course of individual
symptoms should not be combined into a summed score,
rather the patient's overall rating of the condition should be
used (484). QoL methods have produced validated questionnaires
which measure the impact of overall rhinosinusitis symptoms
on everyday life (461).
6-1-3-6 Chronic Sinusitis Survey (CSS)
This is a 6 item duration based monitor of sinusitis specific
outcomes which has both systemic and medication-based sections (485). In common with other questionnaires, it is rather better at determining the relative impact of chronic rhinosinusitis
compared to other diseases than as a measure of improvement
following therapeutic intervention but can be a useful tool (462,
486)
[Evidence Level IIb]. Mean scores one year after endoscopic
frontal sinus surgery showed a significant improvement in
symptoms of pain, congestion, and drainage and medication
use was also significantly reduced (487).
6-1-3-7 The Chronic Rhinosinusitis Type Specific Questionnaire
This test contains three forms. Form 1 collects data on nasal
and sinus symptoms prior to treatment, Form 2 collects data
37
interventions eg at 3, 6, 9 and 12 months. This has a high interrater concordance (489). A number of staging systems for polyps
have been proposed (490-492). Johansson showed good correlation
between a 0 3 scoring system and their own system in which
they estimated the percentage projection of polyps from the
lateral wall and the percentage of the nasal cavity volume occupied by polyps. However, they did not find a correlation
between size of polyps and symptoms. (Level III).
0-Absence of polyps;
1-polyps in middle meatus only;
2-polyps beyond middle meatus but not blocking the nose completely;
3-polyps completely obstructing the nose.
Oedema: 0-absent; 1-mild; 2-severe.
Discharge: 0-no discharge; 1-clear, thin discharge; 2-thick, purulent
discharge.
Scarring: 0-absent; 1-mild; 2-severe.
Crusting: 0-absent; 1-mild; 2-severe.
6-2-4 Imaging
Plain sinus x-rays are insensitive and of limited usefulness for
the diagnosis of rhinosinusitis due to the number of false positive and negative results (501-503). Nevertheless it can be usefull to
prove ARS in studies.
6-2 Examination
Table 6-2. Bacteriology of Rhinosinusitis; Correlation of middle meatus versus maxillary sinus
author
no of samples
type of rhinosinusitis
technique
concordance
21
chronic
85.7%
65
chronic
73.8%
16
acute
93%
29
60%
46
acute
90.6%
Joniau et al 2005
26
acute
88.5%
(497)
(498)
38
Supplement 20
left
right
maxillary (0,1,2)
anterior ethmoids (0,1,2)
posterior ethmoids (0,1,2)
sphenoid (0,1,2)
frontal (0,1,2)
ostiomeatal complex
(0 or 2 only)*
total points
0-no abnormalities; 1-partial opacification; 2-total opacification.
*0-not occluded; 2-occluded
39
Sources of some commercially available and validated olfactory tests are also mentioned in the appendix.
6-2-8 Aspirin and other challenges
Objective experiments to differentiate patient groups according
to rhinosinusitis severity or aetiology have been done using
nasal provocation with histamine or metacholine (553, 554) which
test mucosal hyper-reactivity. The tests can differentiate subpopulations with statistical significance, but because of considerable overlap of results, these tests have not achieved the
equivalent position in rhinitis severity evaluations as the corresponding bronchial tests i.e in asthma diagnosis.
Establishing a diagnosis of aspirin hypersensitivity is important
since it provides the patient with a long list of common drugs
that must not be taken in view of the risk of a severe reaction. It
diagnoses a particular type of asthma and sinonasal disease and
allows choice of a specific therapy, i.e. aspirin desensitization.
The oral aspirin challenge test was introduced to clinical practice in the early 1970s (555). Over the following years it was validated and more frequently used (556-558). An inhalation test was
introduced in 1977 by S Bianco. This challenge is safer and
faster to perform than the oral one, although less sensitive.( (559561)
. Contrary to the oral challenge it does not produce systemic
reactions. The nasal provocation test was employed in the late
1980s (562, 563). It is recommended especially for patients with predominantly nasal symptoms and those in whom oral or
inhaled tests are contraindicated because of the asthma severity. A negative nasal challenge should be followed by oral challenge. Lysine aspirin, the only truly soluble form of aspirin
must be used for both respiratory routes. Test procedures have
recently been reviewed in detail (564). The sensitivity and specificity of the tests are shown in Table 6-4.
Table 6-4. Diagnosis of aspirin sensitivity
history
specificity (%)
oral
77
93
bronchial
77
93
nasal
73
94
40
Supplement 20
41
6-3-2-8 SN-5
SN-5 is a validated HRQoL instrument that can be used to
measure childs QoL in relation to chronic sinonasal symptoms
(584, 585)
. The SN-5 domains are sinus infection, nasal obstruction, allergy symptoms, emotional distress, and activity limitations. The information for the questionnaire is given by a
childs caregiver.
6-3-3 Results
6-3-3-1 General (generic) questionnaires
In three generic SF-36 surveys the scores of chronic rhinosinusitis patients were compared to those of a healthy population. The results showed statistically significant differences in
seven of eight domains (572, 586, 587). Two studies have reported that
patients with chronic rhinosinusitis have more bodily pain and
worse social functioning than for example patients with chronic obstructive pulmonary disease, congestive heart failure, diabetes, or back pain (572, 588).
The EuroQol, SF-36 and McGill pain questionnaire were used
to assess 56 patients with refractory CRS in an RCT investigating use of filgrastim. Baseline results confirmed that patient
QOL was below normal and suggested an improvement
(though not significant) in the actively treated group (572).
The effect of surgical treatment was studied with generic questionnaires preoperatively and usually 3, 6 or 12 months after
the operation (512, 573, 587). Following endoscopic sinus surgery, the
SF-36 questionnaire demonstrated a return to normality in all
eight domains six months post-operatively which was maintained at twelve months (569). In a study by Gliklich and Metson
after the sinus surgery significant improvements were found in
reduction of the symptoms and medications needed (486).
Significant improvements in general health status were noted
in six of eight categories, and most attained near-normative
levels. Oral steroid treatment also had a similar effect on
HRQoL as surgery as measured by SF-36 (587).
Radenne et al. have studied the QoL of nasal polyposis
patients using a generic SF-36 questionnaire (568). Polyposis
impaired the QoL more than for example perennial rhinitis.
Treatment significantly improved the symptoms and the QoL
of the polyposis patients. FESS surgery on asthmatic patients
with massive nasal polyposis improved nasal breathing and
QoL, and also the use of asthma medications was significantly
reduced (589).
In a recent study evaluating the effect of radical surgery on
QoL, the SF36 and McGill Pain questionnaires were used on
23 patients who underwent Denkers procedures. Both ques-
42
Supplement 20
43
7. Management
7-1 Treatment of rhinosinusitis with corticosteroids
The introduction of topically administered glucocorticoids has
improved the treatment of upper (rhinitis, nasal polyps) and
lower (asthma) airway inflammatory disease. The clinical efficacy of glucocorticoids may depend in part on their ability to
reduce airway eosinophil infiltration by preventing their
increased viability and activation. Both topical and systemic
glucocorticoids may affect the eosinophil function by both
directly reducing eosinophil viability and activation (370, 427, 595, 596)
or indirectly reducing the secretion of chemotactic cytokines
by nasal mucosa and polyp epithelial cells (368, 597-599). The potency
of these effects is lower in nasal polyps than in nasal mucosa
suggesting an induced inflammatory resistance to steroid treatment in chronic rhinosinusitis / nasal polyposis (596, 597).
The biological action of glucocorticoids is mediated through
activation of intracellular glucocorticoid receptors (GR) (600),
expressed in many tissues and cells (601) Two human isoforms of
GR have been identified, GR and GR, which originate from
the same gene by alternative splicing of the GR primary transcript (602) . Upon hormone binding, GR ?enhances antiinflammatory or represses proinflammatory gene transcription,
and exerts most of the anti-inflammatory effects of glucocorticoids through protein-protein interactions between GR and
transcription factors, such as AP-1 and NF-B. The GR isoform does not bind steroids but may interfere with the GR*
function. There may be several mechanisms accounting for the
resistance to the antiinflammatory effects of glucocorticoids,
including an overexpression of GR or a downexpression of
GR . Increased expression of GR has been reported in
patients with nasal polyps (603, 604) while downregulation of GR*
levels after treatment with glucocorticoids (605, 606) has also been
postulated to be one of the possible explanations for the secondary glucocorticoid resistance phenomenon.
The anti-inflammatory effect of corticosteroids could, theoretically, be expected as well in non-allergic (i.e. infectious) as in
allergic rhinosinusitis. Tissue eosinophilia is thus also seen in
CRS (259).
Indications for corticosteroids in rhinosinusitis:
Acute rhinosinusitis;
Prophylactic treatment of acute recurrent rhinosinusitis;
Chronic rhinosinusitis without NP;
Chronic rhinosinusitis with NP;
Postoperative treatment of chronic rhinosinusitis with or
without NP.
7-1-1 Acute rhinosinusitis
44
Supplement 20
(615)
assessed in a double
drug
antibiotic
number
effect
X-ray
level of
evidence
budesonide
erythromycin
20
mucosal thickening =
no effect
Ib
flunisolide
amox/clav
180
no effect on x-ray
Ib
budesonide
amox/clav
89 (children)
improvement in cough and nasal secretion seen at the end of the second
week of treatment in the BUD group
not done
Ib
mometasone
furoate
amox/clav
407
no statistical difference
in CT outcome
Ib
fluticasone
propionate
cefuroxime
axetil
95
significant effect.
effect measured as clinical success
depending on patients self-judgment
of symptomatic improvement
not done
Ib
mometasone
furoate
amox/clav
967
no statistical difference
in CT outcome
Ib
Meltzer, 2005
mometasone
furoate
981
not done
Ib
(607)
45
drug
antibiotic
number
effect
level of
evidence
8 mg metylprednisolone TDS
amoxicillin
clavulanate
417
no statistical difference
at 14 days
Ib
oral prednisone
cefpodoxime
289
Ib
blind, randomised study in parallel groups the efficacy and tolerance to prednisone administered for 3 days in addition to cefpodoxime in adult patients presenting with an acute bacterial rhinosinusitis (proven by culture) with severe pain. The assessments made during the first 3 days of treatment showed a statistically significant difference in favour of the prednisone group
regarding pain, nasal obstruction and consumption of paracetamol. There was no difference between the two groups after the
end of the antibiotic treatment. The tolerance measured
throughout the study was comparable between the two groups.
Pain is significantly relieved during treatment with prednisone
but after 10 days on antibiotics there was no difference
between the two groups. Evidence level for steroids as pain
reliever: I but there is no evidence for a more positive long
term outcome compared to placebo.
7-1-2 Prophylactic treatment of recurrent episodes of acute rhinosinusitis
In a study by Puhakka et al (616) FP (200 g four times daily) or
placebo were used for 6 days in 199 subjects with an acute
common cold, 24-48 hours after onset of symptoms to study
the preventive effects of FP on risk for development of ARS.
Frequency of sinusitis at day 7 in subjects positive for rhinovirus, based on x-ray, was 18.4% and 34.9% in FP and placebo group respectively (p=0.07) thus indicating a non-significant
effect of FP.
Cook et al. randomized, as a continuation of an acute episode
of rhinosinusitis, patients with at least 2 episodes of rhinosinusitis in the previous 6 months or at least 3 episodes in the
last 12 months for a double blind, placebo-controlled study
with FP, 200 mcg QD. 227 subjects were included. Additionally
cefuroxime axetil 250 mg BID was used for the first 20 days.
39% had a recurrence in the placebo group and 25% in the FP
group (p=0.016) during the seven week follow-up period. Mean
number of days to first recurrence was 97.5 and 116.6 respectively (p=0.011) (617).
There is very low evidence for a prophylactic effect of nasal
corticosteroids to prevent recurrence of ARS episodes.
7-1-3 Chronic rhinosinusitis without nasal polyps
7-1-3-1 Topical corticosteroid chronic rhinosinusitis without
nasal polyps
Parikh et al (618) performed a randomized, double blind, placebo-controlled trial on patients with chronic RS on two groups
with respectively 9 and 13 subjects (2 subjects in each group
with nasal polyps) to test fluticasone propionate for 16 weeks.
No significant improvement was seen, as measured by symptom scores, diary card, acoustic rhinometry or endoscopy. No
side effects were seen in either group.
In another double blind placebo controlled study on patients
with CRS (without NP) with allergy to house dust mite and
who had recently been operated on but still had signs of
chronic RS, 256 ug budesonide (BUD) or placebo was instilled
into the maxillary sinus once a day through a sinus catheter for
three weeks (619). A regression of more than 50% of total nasal
symptom scores was seen in 11/13 in the BUD group and 4/13
in placebo group. The effect was more long term in BUD
group, i.e. 2-12 months compared with less than 2 months in
the placebo group (who had experienced an effect during the
catheter period). A significant decrease was also seen in BUD
group after three weeks treatment for CD-3, eosinophils and
cells expressing IL-4 and IL-5.
In a study by Cuenant et al (620) tixocortol pivalate was given as
endonasal irrigation in combination with neomycin for 11 days
in a double blind placebo controlled in patients with chronic
RS. Maxillary ostial patency and nasal obstruction was signifi-
drug
number
time (weeks)
effect
comments
level of evidence
FP
199
N.S.
common cold
Ib
FP
227
Ib
46
Supplement 20
nasal polyps
Mygind et al (623) showed that beclomethasone dipropionate
(BDP) 400ug daily for three weeks reduced nasal symptoms in
19 patients with NP compared to a control group of 16 patients
treated with placebo aerosol. Reduction of polyp size did not
differ in this short treatment study.
In another study with BDP 400 ug daily for four weeks (double
blind, cross over with 9 and 11 subjects in each group),
Deuschl and Drettner (624) found a significant improvement in
nasal symptoms of blockage and nasal patency as measured
with rhinomanometry. Difference in size of polyps was, however, not seen.
Holopainen et al (625) showed in a randomized, double blind,
paralell, placebo controlled study with 400 mcg budesonide
(n=19) for 4 months that total mean score and nasal peak flow
were in favour for budesonide. Polyps also decreased in size in
the budesonide group.
Tos et al (626) also showed that budesonide in spray (128 mcg)
and powder (140 mcg) were both significantly more effective
than placebo (multicentre) concerning reduction of polyp size,
improvement of sense of smell, reduction of symptom score
and overall assessment compared to placebo.
7-1-4-1
Table 7-4. Treatment with nasal corticosteroids in chronic rhinosinusitis without nasal polyposis
study
drug
number
time
symptoms
other effects
level of evidence
tixocortol
irrigation
60
11 days
Ib
dexamethasone
+ tramazoline
50
4 wks
IIa
fluticasone
propionate
22
16 wks
not significant
Ib
intrasinus
budesonide
26
3 wks
T-cells,
eosinophils
mRNA for IL-4, and IL-5
significantly improved
Ib
budesonide
134
20 wks
significant improvement in
airway using PNIF
Ib
47
48
Supplement 20
Table 7-5. Treatment with nasal corticosteroids in chronic rhinosinusitis with nasal polyposis
study
drug
number
treatment time
(weeks)
objective measures
(*stat sig)
effect on polyps
BDP
35
BDP
20
2x4weeks
Bud
19
Vendelo Johansen,
1993 (627)
Bud
n.s.
Ib
blockage*
rhinomanometry*
n.s.
Ib
16
yes
Ib
91
12
blockage*
sneezing*
secretion*
sense of smell N.S.
yes
Ib
Bud
116
blockage*
sneezing*
secretion*
sense of smell N.S.
yes
Ib
FP/BDP
55
26
yes in BDP
Ib
Bud
138
yes
Ib
FP/BDP
29
12
blockage*
rhinitis N.S.
yes FP
Ib
FPND
104
12
blockage*
rhinitis*
sense of smell N.S.
n.s.
Ib
FP
142
12
blockage*
rhinitis*
sense of smell N.S.
yes
Ib
betametasone
46 CF
children
N.S.
yes
Ib
fluticasone
propionate
nasal drops
54
12
nasal obstruction *
rhinorrhea * postnasal
drip *
and loss of smell *
yes
Ib
Mometasone
354
16
obstruction*
loss of smell*
rhinorrhea*
yes
Ib
Mometasone
310
16
obstruction*
loss of smell N.S.
rhinorrhea*
200ug OD no
200ug BID yes
Ib
Stjrne et al 2006
Mometasone
298
16
obstruction*
loss of smell *
rhinorrhea*
QOL
yes
Ib
(634)
level of
evidence
49
Damm et al. (643) showed a good effect with combined treatment using topical steroids (budesonide, unknown doses) and
oral treatment with fluocortolone 560 mg or 715 mg in 2 different groups of patients with 20 severe cases of CRS with NP.
This study was not controlled. A large improvement of symptoms was seen (80%) and improvement on MRI (>30% reduction of MRT-pathology) was observed in 50%.
(647)
drug
number
dose/time
betametamethasone/BDP
53
?/52 weeks
Lildholt, 1997
effect symptoms
yes
effect polyps
level of evidence
yes
III
yes
III
betametamethasone/budesonide
16
14mg/52 weeks
yes
prednisolone 60 mg
25
2 weeks
72%
betametamethasone/budesonide
16
14mg/52 weeks
yes
budesonide + fluocortolone
20
yes
III
prednisone + Budesonide
84
2 weeks/10 weeks
yes
yes
Ib
prednisolone
41
50mg/2 weeks
yes
yes
Ib
(493)
yes (10/22)
yes
III
III
50
Supplement 20
0.75 mg
Cortisone acetate
25 mg
Dexamethasone
0.75 mg
Hydrocortisone
20 mg
Methylprednisolone
4 mg
Prednisolone
5 mg
Prednisone
5 mg
Triamcinolone
4 mg
Table 7-8. Nasal corticosteroids in the post operative treatment of persistant rhinosinusitis to prevent recurrences of NP
study
drug
number
treatment
time (weeks)
BDP
40
52
blockage
IV
flunisolide
22
12
Ib
BDP
40
120
not described
IIa
flunisolide
41
52
blockage*
sneezing*
Ib
BUD
73
26
blockage N.S.
Ib
Dijkstra 2004
fluticasone
propionate
162
52
not seen
Ib
fluticasone
propionate
109
5 years
Ib
(651)
level of evidence
51
The safety of nasal and oral corticosteroids has been the subject
of concern in medical literature since many patients with chronic
sinus disease are prescribed these drugs due to their good efficacy. Suppression of the hypothalamic-pituary-adrenal axis, osteoporosis or changes in bone mineral density, growth retardation in
children, cataracts and glaucoma have been reported to be the
main adverse effects of corticosteroid treatment (653). In relation to
adverse effects of corticosteroids, it is obvious that a clear distinction needs to be made between nasal and oral corticosteroids.
Nasal corticosteroid treatment represents one of the long-term
treatment modalities in patients with chronic sinus disease. It
is well established that absorption into the systemic circulation
takes place after nasal administration of corticosteroids.
However, several factors influence the systemic absorption,
like the molecular characteristics of the corticosteroid, the prescribed dose, the mode of delivery and the severity of the
underlying disease (653). There is insufficient evidence from the
literature to relate the use of nasal corticosteroids at licensed
doses to changes in bone mineral biology, cataract and glaucoma. Adrenal suppression may occur with some nasal corticosteroids at licensed doses, but the clinical relevance remains
uncertain. Overuse of nasal corticosteroids may be responsible
for adrenal insufficiency and decrease in bone mineral density
(654)
. Of note, inhaled corticosteroids are the mainstay of treatment for children and adults with asthma and are more often
associated with systemic side effects than the nasal route of
treatment for rhinosinusitis (655).
Nasal corticosteroid-induced septal perforation is rarely
described in literature (656). Whether septal perforation relates to
repeated traumas of the nasal mucosa and septal cartilage by
the nasal device, to the underlying nasal disorder for which
corticosteroids were prescribed or to a direct adverse effect of
the steroid used, remains unclear.
Short treatment with oral corticosteroids is effective in chronic
rhinosinusitis with nasal polyps. It is obvious that repeated or
prolonged use of oral corticosteroids is associated with a significantly enhanced risk of the above mentioned side effects (657).
52
The reviewers conclude that in acute maxillary sinusitis confirmed radiographically or by aspiration, current evidence is
limited but supports the use of penicillin or amoxicillin for 7 to
14 days. Clinicians should weigh the moderate benefits of
antibiotic treatment against the potential for adverse effects (40).
It is interesting to see that in this review the local differences
in susceptibility of micro-organisms to the antibiotics used is
not acknowledged, although total cumulative meta-analysis of
studies ordered by year of publication did not show a trend
towards reduced efficacy of amoxicillin compared to newer
non-penicillin antibiotics. Resistance patterns of predominant
pathogens like Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis, vary considerably (47, 48). The
prevalence and degree of antibacterial resistance in common
respiratory pathogens are increasing worldwide. The association between antibiotic consumption and the prevalence of
resistance is widely assumed (50). Thus the choice of agent may
not be the same in all regions, as selection will depend on local
resistance patterns and disease aetiology. (50, 661). Moreover one
might wonder whether the limited benefits of antibiotic treatment outweigh the considerable threat of antibiotic resistance.
In 1995, upper respiratory tract infection was the most frequent
reason for seeking ambulatory care in the United States, resulting in more than 37 million visits to physician practices and
emergency departments (662).
placebo
difference in time to
improvement
Time Units
end of study
(i.e. 3-12
weeks)
end of
therapy
(variable
duration)
7-2-2-1 Introduction
It is significantly more difficult to evaluate the efficacy of
antibiotic treatment in CRS compared to ARS, because of the
conflicts in terms of terminology and definition of the clinical
picture of CRS in the literature. In most studies, no radiological diagnosis, such as CT, has been performed confirm the
diagnosis of chronic rhinosinusitis. The data supporting the
use of antibiotics in this condition, however, are limited and
lacking in terms of randomized placebo controlled clinical
trials.
randomize
treatement or
placebo
symptoms at
least
7-10 days
Supplement 20
Figure 7-1. Adapted from Rhinosinusitis: Developing guidance for clinical trials (6, 673). The rationale for the illustrated study design is to determine the effect of a treatment intervention on the clinical course of
ARS, as measured by time to resolution of symptoms. Patient symptoms, QOL, or both are measured on the y-axis, and time is measured
on the x-axis. The therapeutic intervention that is to be tested can be
compared with either placebo or a comparator intervention. Success of
the treatment intervention is based on a statistically significant difference in rate of symptom (or QOL) resolution between the comparator
interventions. This graph is intended to convey the conceptual aspects
of the type of study design. Therefore variables, such as timing of intervention, duration of treatment, type of intervention, and end of study,
can be modified based on the specifics of the proposed study. Modified
from Meltzer et al Rhinosinusitis:developing guidance for clinical trials
53
drug
number
time/dose
effect on symptoms
evidence
(678)
ceflaclor
vs. amoxycillin
56 ARS
25 recurrent
rhinosinusitis
15 chronic maxillary sinusitis
2x 500mg
3x500mg
for 10 days
clinical improvement:
ARS 86%
recurrend 56%
CRS.
no statistics
Ib
ciprofloxacin
vs. amoxycillin
clavulanate
251
9 days
Ib
McNally et al,
1997 (674)
oral antibiotics
200
4 weeks
III
Subramanian et al;
2002 (675)
antibiotics
10 days corticosteroids
40
4 6 weeks
III
Namyslowski et al,
2002 (677)
amoxycillin clavulanate
vs. cefuroxime axetil
206
875/125mg for
14 days
500mg
for 14 days
clinical cured:
amx/ca 95%
cefurox 88%
bacterial eradication:
amx/ca 65%
cefurox 68%
clinical relapse:
amx/ca 0/ 98
cefurox 7/89
Ib
54
Supplement 20
Huck et al. compared in a double-blind, randomized trial compared cefaclor with amoxicillin in the treatment of 56 acute, 25
recurrent, and 15 chronic maxillary sinusitis: Whether treated
with cefaclor or amoxicillin, clinical improvement occurred in
86% of patients with ARS and 56% of patients with recurrent
RS. Patients with CRS were too few to allow statistical analysis. The susceptibility of organisms isolated to the study drugs
was unrelated to outcome (678).
To summarize, at the moment no placebo-controlled studies
on the effect of antibiotic treatment are available. Studies comparing antibiotics have level II evidence and do not show significant differences between ciprofloxacin vs. amoxycillin/clavulanic acid, and cefuroxime axetil. The few available prospective
studies show effect on symptoms in 56% to 95% of the patients.
It is unclear which part of this effect is regression to the mean
because placebo controlled studies are lacking. There is urgent
need for randomized placebo controlled trials to study the
effect of antibiotics in CRS and exacerbations of chronic rhinosinusitis.
7-2-2-3 Long-term treatment with antibiotics in chronic rhinosinusitis
The efficacy of long term treatment with antibiotics in diffuse
panbronchiolitis, a disease of unclear aetiology, characterized
by chronic progressive inflammation in the respiratory bronchioles inspired the Asians in the last decade to treat CRS in
the same way (679, 680). Subsequently a number of clinical reports
have stated that long-term, low-dose macrolide antibiotics are
effective in treating CRS incurable by surgery or glucocorticosteroid treatment, with an improvement in symptoms varying
between 60% and 80% in different studies (23, 679, 681, 682). The
macrolide therapy was shown to have a slow onset with ongoing improvement until 4 months after the start of the therapy.
In animal studies macrolides have increased mucociliary transport, reduced goblet cell secretion and accelerated apoptosis of
neutrophils, all factors that may reduce the symptoms of
chronic inflammation. There is also increasing evidence in
vitro of the anti-inflammatory effects of macrolides. Several
studies have shown macrolides inhibit interleukin gene expression for IL-6 and IL-8, inhibit the expression of intercellular
adhesion molecule essential for the recruitment of inflammatory cells. However, it remains to be established if this is a clinically relevant mechanism (683-689).
There is also evidence in vitro, as well as clinical experience,
showing that macrolides reduce the virulence and tissue damage caused by chronic bacterial colonization without eradicating the bacteria. In addition long term treatment with antibiotics has been shown to increase ciliary beat frequency (690). In a
prospective RCT from the same group (536) ninety patients with
polypoid and nonpolypoid CRS were randomised to medical
treatment with 3 months of an oral macrolide (erythromycin)
or endoscopic sinus surgery and followed over one year.
Outcome assessments included symptoms (VAS), the
SinoNasal Outcome Test (SNOT-22), Short Form 36 Health
Survey (SF36), nitric oxide, acoustic rhinometry, saccharine
clearance time and nasal endoscopy. Both the medical and sur-
drug
number
time/dose
effect symptoms
level of
evidence
Gahdhi et al,
1993 (682)
prophylatic
antibiosis
details not
mentioned
26
not mentioned
III
Nishi et al,
1995 (681)
clarithromycin
32
400mg /d
III
Scadding et al
1995 (690)
oral antibiotic
therapy
10
3 month
III
Ichimura et al,
1996 (23)
roxithromycin
20
III
roxithromycin
and azelastine
20
150mg /d
for at least 8 weeks
1mg /d
Hashiba et al,
1996 (679)
clarithromycin
45
400mg /d
for 8 to 12 weeks
III
Suzuki et al,
1997 (680)
roxithromycin
12
150mg /d
III
Ragab et al
2004 (536)
erythromycin
v ESS
45 in each
arm
3 months
improvement in upper & lower RT symptoms, SF36, SNOT22, NO, Ac Rhin, SCT, nasal endoscopy at 6 & 12 mnths
Ib
Wallwork 2006
roxithromycin
64
3 months
Ib
(691)
RT: respiratory tract; SF 36: Short Form 36 QoL; SNOT-22: SinoNasal Outcome Test; NO:expired nitric oxide, Ac Rhin: acoustic rhinometry; SCT:
saccharine clearance time.
55
gical treatment of CRS significantly improved almost all subjective and objective parameters, with no significant difference
between the two groups nor between polypoid and nonpolypoid CRS except for total nasal volume which was greater after
surgery and in the polypoid patients.
tered thrice daily to the nasal passages by means of a large-particle nebulizer apparatus for 4 weeks in twenty patients with
CRS refractory to medical and surgical therapy. He found no
significant difference between the groups and concluded that
large-particle nebulized aerosol therapy may offer a safe and
effective management alternative for patients with refractory
rhinosinusitis irrespective of the addition of gentamicin (698).
56
Supplement 20
7-3-2 Mucolytics
7-3-2-1 Acute rhinosinusitis
Mucolytics were used as adjuncts to antibiotic treatment and
decongestant treatment in ARS in order to reduce the viscosity
of sinus secretion. The benefit of such treatment has not been
evaluated in many trials. In paediatric rhinosinusitis, a RCT
(Ib) did not prove bromhexine superior to saline in inhalation
for children with CRS (717). A second RCT (Ib) suggested
bromhexine was superior to placebo (718).
7-3-2-2 Chronic rhinosinusitis
A cohort study in a mixed group of 45 ARS and CRS patients
suggested beneficial effect of adding mucolytic to standard rhinosinusitis treatment in terms of reducing treatment duration
(719)
(evidence level III).
7-3-2-3 Nasal polyps
No clinical trials have tested the effect of mucolytics in nasal
polyp treatment.
7-3-3 Antihistamines, cromones
7-3-3-1 Acute rhinosinusitis
The beneficial effect of loratadine in terms of symptom reduction for the treatment of ARS in patients with allergic rhinitis
was confirmed in a multicentre randomized double-blind, placebo controlled trial (Ib)(720). Patients receiving loratadine as an
adjunct to antibiotic treatment suffered significantly less sneezing and obstruction on daily VAS scores, and overall improvement was confirmed by their physicians. Cromolyn did not
prove better than saline in a RCT (Ib) for treatment of acute
hyperreactive sinusitis measured by subjective scores and ultrasound scans, leading to 50% improvement in both groups (721). A
RCT (Ib) for acute paediatric rhinosinusitis did not confirm any
benefit of oral antihistamine-nasal decongestant drops (707).
7-3-3-2 Chronic rhinosinusitis
Although generally not recommended as rhinosinusitis treatment, an evaluation study of CRS treatment in the USA
revealed antihistamines as rather often presribed medication in
patients with CRS (an average of 2.7 antibiotic courses; nasal
steroids and prescription antihistamines 18.3 and 16.3 weeks,
respectively, in a 12-month period) (722). However, no evidence
of beneficial effects of antihistamine treatment for CRS is
found, as there are no controlled trials evaluating such treatment.
7-3-3-3 Nasal polyps
Cetirizine in a dose of 20 mg/day for three months, significantly reduced sneezing, rhinorrhoea and obstruction compared to
placebo in the postoperative treatment of recurrent polyposis
but with no effect on polyp size (Ib) (723).
57
7-3-3-4 Antihistamines
Unlike first generation antihistamines, where central nervous
system and peripheric muscarinic side effects are significant,
frequency of side effects in newer second generation antihistamines is low. The most commonly reported events during
treatment with second generation antihistamines were upper
respiratory tract infection, wheezing, vulvitis, cough, headache,
migraine, drowsiness, sedation and injury, most of them
reported in 1 to 5% of the treated population, however, not
necessarily related to medication. Although caution with cardiotoxicity and potential for interaction with drugs metabolised
by the hepatic cytochrome P450 system, applied to older nonsedating antihistamines (like terfenadine or astemizole), this
risk seems to be absent in newer compounds (desloratadine,
levocetirizine, fexofenadine), at least in recommended treatment regimens.
7-3-4 Antimycotics
Antimycotics are used as topical and systemic treatment, as an
adjunct to sinus surgery, in allergic fungal, and invasive fungal
rhinosinusitis, especially in immunocompromized patients (724).
Surgery is considered the first line treatment for allergic fungal
(725)
and invasive fungal rhinosinusitis (726). Although the use of
antimycotics in the treatment of allergic fungal rhinosinusitis
has not been tested in controlled trials, high dose postoperative itraconazole, combined with oral and topical steroids in a
cohort of 139 patiens with AFS reduced the need for revision
surgery rate to 20.5% (727). The state-of-art treatment for invasive
fungal sinusitis is based on small series of patients and case
reports, which do not meet the criteria for meta-analysis and
may be considered as level IV evidence.
7-3-4-1 Acute rhinosinusitis
No controlled trials for antimycotic treatment for ARS was
found on the Medline search.
7-3-4-2 Chronic rhinosinusitis
The fungal hypothesis, based of the premise of an altered local
immune (non-allergic) response to fungal presence in
nasal/sinus secretions resulting in the generation of chronic
eosinophilic rhinosinusitis and nasal polyposis (148), has led to
idea of treating CRS with and without NPs with a topical
antimycotic. Although the presence of fungus in sinus secretions was detected in a high proportion (< 90%) of patients
with CRS, as well as in a control disease-free population in a
few study centres (148, 149), it cannot be taken as proof of aetiology. Until recently a few case studies (level IV) had been conducted (728, 729). Ponikau et al, in a group of 51 patients with CRS,
including polyposis patients, treated patients with topical
amphotericin B as nasal/sinus washing, without placebo or
other control treatment. The treatment resulted in 75% subjective improvement and 74% endoscopic improvement (728). As
the authors stated, antifungal treatment should be evaluated in
a controlled trial to be justified.
58
Supplement 20
In a recent small randomized, placebo-controlled, doubleblind, trial using amphotericin B to treat 30 patients with CRS
with or without NP Ponikau et al (730) were also not able to
show significant effect on symptomatology although did show
a reduced inflammatory mucosal thickening on both CT scan
and nasal endoscopy and decreased levels of intranasal markers for eosinophilic inflammation in patients with CRS (a significant difference in the reduction of eosinophil derived neurotoxin (EDN), but not Il-5). The study by Weschta et al(731) did
not reveal difference between amphotericin B and placebo
treatments in the reduction of eosinophil cationic protein and
tryptase, and no difference was found between cellular activation markers whether fungal elimination was achieved or not
(for patients where fungal elements were detected), which supports the hypothesis that fungi are innocent bystanders and not
the trigger for inflammatory (presumably eosinophil) cells activation (731). Both trials used antimycotic solutions high above
minimal inhibitory concentration for fungal elimination.
However, the Ponikau trial used nasal lavage twice daily for 6
months (with significant endoscopic improvement after 3 and 6
months), while Weschta et al used nasal spray 4 times daily for
3 months. While difference in drug application and small sample size left the question of treatment success and different
objective outcomes between the trials open, a multicentre randomized, placebo-controlled, double-blind, trial (156), in 120
patients (80% with polyps) using nasal lavage for 3 months and
confirmed no benefit with amphotericin B added to nasal
lavage compared with placebo lavage in the treatment of CRS
with and without NPs. No difference between amphotericin B
and placebo was found in terms of subjective and objective
measures of improvement, i.e. mean VAS score , Sf-36,
Rhinosinusitis Outcome Measure-31 (RSOM-31), endoscopy
scores , SF-36, PNIF and polyp scores. Patients on placebo
improved in total VAS, postnasal drip VAS, rhinorrhea VAS in
non-asthma subgroup; PNIF deteriorated significantly on
amphotericin B, though did not in those on placebo (156).
Oral antifungal treatment with high dose terbinafine for 6
weeks in a randomized, placebo-controlled, double-blind,
indication
treatment
number
duration
symptoms
objective
level of
evidence
Weschta, 2004
NP
amphotericin B spray
vs placebo 4 times
daily
60
8 weeks
significantly worse on
amphotericin B
no difference on CT,
endoscopy, ECP and
tryptase in lavage
Ib (-)
CRS + NP
amphotericin B lavage
vs. placebo twice
daily
30
6 months
no difference
CT less mucosal
thickening and EDN,
but not Il-5 in lavage
for active treatment
Ib (+ only
for CT)
CRS
53
6 weeks + 9
week follow up
no difference in
symptoms and RSDI
patient and physician
no difference in CT,
MRI, endoscopy
Ib (-)
CRS + NP
amphotericin B lavage
vs. placebo
116
3 months
no difference
no difference in
polyp scores, PNIF,
RSOM-31, SF-36
between groups
Ib (-)
(731)
Ponikau, 2005
(730)
Kennedy, 2005
(732)
Ebbens, 2006
(156)
59
nosinusitis. The beneficial effect of antibiotic treatment is declining together with the increased microbial resistance after repeated treatments. Such patients are usually regarded as difficult-totreat, and usually unresponsive in the long-term to medical and
surgical treatment. As altered immune response is expected to be
responsible for frequent recurrence, different immunomodulators or immunostimulants have been tested in such patients. The
most common form of medications used are bacterial lysates.
Efficacy of bacterial lysate preparations (Enteroccocus faecalis
autolysate (739), ribosomal fractions of Klebsiella pneumoniae,
Streptococcus pneumoniae, Streptococcus pyogenes,
Haemophilus influenzae and the membrane fraction of Kp (740),
and mixed bacterial lystate (741) in terms of the reduction of the
number of acute relapses in CRS, the period between the relapses and need for antibiotic treatment, have been tested in multicentre, placebo controlled RCTs (Ib) (739-741).
indication
treatment
number
duration
symptoms
objective
level of
evidence
recurrent ARS
Enterococcus
faecalis
157
6+8 months
reduced acute
episodes
Ib
recurrent ARS
Ribomunyl
327
6 months
reduced acute
episodes
Ib
CRS
Bronchovaxom
284
6 months
Ib
60
Supplement 20
61
often reported. However, randomized controlled trial comparing isotonic and hypertonic saline for ARS or common cold
reported significantly higher rate of nasal irritation for hypertonic saline (32% vs. 13% for saline, respectively), while dry
nose was more common in patients using saline (36%), than in
those using hypertonic saline (21%) (746).
Uncommon side effects were nausea caused by drainage, burning, cough, drowsiness and tearing. Interestingly, side effects of
HS were less common in the treatment of CRS (6 months):
nasal irritation, nasal burning, tearing, nosebleeds, headache,
or nasal drainage were reported by 23% of the subjects, 80% of
those who reported side effects, regarded them as not significant (750).
Comparison of treatment with antral washouts in the treatment of chronic adult (754) and paediatric rhinosinusitis (755) did
not prove benefit from such treatment. In a RCT by Pang et al.
patients received either antral washouts followed by antibiotics
and topical nasal steroids or antibiotics and topical nasal
steroids alone. In each group 51.6 per cent and 50 per cent of
patients respectively improved with treatment (754).
Instead of using saline or hypertonic solution, a few non-controlled pilot trials in a small number of patients analyzed the
effect of active medication used intrasinusally. A trial in 12
patients was done using N-chlorotaurine, an endogenous oxidant with antimicrobial properties against bacteria and fungi.
The intrasinusal application of N-chlorotaurine was done 3
times a week, during 4 weeks (12 applications) using a Yamik
catether and improvement of symtpoms was found in 75 to
90% of patients, however, no improvement was found on the
sinus CT scans, before and after the treament (756).
Although saline washes are frequently recommended postoperatively, level I evidence to support this is lacking.
7-3-7-3 Nasal polyps
Nasal saline has been used as a control treatment in trials on
nasal polyposis with topical steroid, but there are no controlled
trials on saline/hypertonic saline treatment alone in nasal polyposis.
7-3-7-4 Side effects
Side effects of saline, hypertonic saline nasal washings are not
7-3-8 Capsaicin
Capsaicin, the active substance from red hot chilli pepppers, is
a neurotoxin which depletes substance P with some other neurokinins and neuropeptides, leading to long lasting damage of
unmyelinated axons and thinly myelinated axons when repeatedly applied to the respiratory mucosa. Substance P was found
effective in reducing nasal symptoms after cumulative topical
applications in the treatment of non-allergic hyperreactive
rhinitis, probably acting as desenzitizer of nasal mucosa due to
depletion of SP and neurokinins.The hypothesis that neurogenic inflammation may play a role in the pathogenesis of
nasal polyps has led to trials on capsaicin treatment of nasal
polyposis.
7-3-8-1 Acute and chronic rhinosinusitis without nasal polyps
No trials of treatment of acute or chronic rhinosinusitis with
capsaicin could be found.
Table 7-13. Nasal irrigation (saline, hypertonic saline, Dead sea solution, balneotherapeutic water) randomized controlled trials
study
indication
solution
number
duration
symptoms
objective
level of
evidence
ARS
saline vs. HS
vs. NT
119
10 days
no difference
not done
Ib
CRS
40
7 days
improved, no
difference saline
vs EMS
endoscopy, plain
X-ray improved
Ib
Taccariello, 1999
CRS
62
30 days
improved
endoscopy, HRQL Ib
improved
CRS
HT vs. NT
76
6 months
improved
significantly less
antibiotics, nasal
sprays
Ib
CRS in children
saline vs. HS
40
4 weeks
HS all symptoms
improved, saline
PND only
x-ray improved
after HS
Ib
CRS
HS vs.
DSS
57
2 months
DSS significantly
improved, better
than HS
DSS - HRQL
significantly
improved
Ib
saline vs. HS
vs. NT
60
5 postop. days
higher discharge
and pain in HS
group
not done
Ib
Legend. HS: hypertonic saline; DSS: DeadaSea salt solution; NT: no treatment; ESS: endoscopic sinus surgery; HRQL: health related quality of life.
62
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63
bidity (57 articles screened, 14 articles included) (770, 771)). A number of case trials of rhinosinusitis, especially paediatric (770), have
tested the efficacy of anti-reflux treatment with proton pump
inhibitors on the clinical course and symptoms of rhinosinusitis. Increased rates of reflux were detected in CRS in adults
unresponsive to standard treatment (772, 773). Further research is
expected in this field, and such treatment should be justified
by randomized controlled trials.
Non-controlled trials, especially in children, indicate the effect
on some symptoms of rhinosinusitis, presumably postnasal
drip and cough. However, a recent meta-analysis of randomized controlled trials of outcomes of the treatment of non-specific cough with proton pump inhibitors confirmed that it is
insufficient evidence to definitely conclude that reflux treatment with PPI is universally beneficial for cough associated
with reflux in adults. The beneficial effect was only seen in
sub-analysis and its effect was small (774).
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Table 7-14. Other medical management for rhinosinusitis. Results from the treatment studies summarised
acute
treatment
study
level of
evidence
clinical
importance
study
level of
evidence
clinical
importance
study
evidence
clinical
importance
decongestant
1 RCT, 1 CT
Ib (-)
no.
no trial
none
no
no
none
no
trial
mucolytic
2 RCT
Ib (one +,
one -)
no
1 cohort
III (-)
no
no trial
none
no
phytotherapy
1 RCT
Ib
no
1 CT
Ib
no
no trial
none
no
immuno-modulator
no trial
none
no
1 RCT
Ib (-)
no
no trial
none
no
antihistamine
1 RCT allergic
Ib
no trial
none
no
1 RCT allergic
Ib
antileukotriene
no trial
none
no
1 cohort
III
no
3 cohort
III
no
proton pump
inhibitor
no trial
none
no
3 cohort
III
no
no trial
none
no
lysine aspirin
desensitisation
no trial
none
no
no trial
none
no
1 RCT
2 CT
Ib
yes
furosemide
no trial
none
no
no trial
none
no
1 RCT
1 CT
Ib (-)
yes
capsaicin
no trial
none
no
no trial
none
no
1 RCT
Ib
no
anti-Il-5
no trial
none
no
no trial
none
no
1 RCT
Ib (-)
no
65
case series. Patients judgement of outcome using an unbalanced three item verbal rating scale was employed. (804). A very
good result was defined as complete resolution of symptoms or
less than 2 rhinosinusitis episodes per year, a good result was
improvement but without complete resolution of symptoms or
2-5 sinusitis episodes per year, and a poor result was no
improvement or deterioration. Articles reporting a total of 1,713
patients were evaluated. Subjectively, 63% of patients reported a
very good result, 28% a good result, and 9% an unsatisfactory
result. Twelve percent of patients required revision surgery and
complications occurred in 1.6% of patients. With 1.5%, bleeding
was most the most common complication (level IV).
In a systematic review, 12 case series of endoscopic sinus
surgery were evaluated and compared with 6 case series of
conventional techniques (797). In patients with CRS with or without polyps, overall success rates ranging from approximately
70% to 90% after sinus surgery were reported. Revision surgery
was reported in 7% to 10%. If reported, complications were
below 1% (level IV).
In a recent meta-analysis, the impact of endoscopic sinus
surgery on sinus symptoms and quality of life was evaluated in
adults after failed medical treatment (803). Articles dealing with
both or not differentiating between CRS with and without
polyps were included. Forty-five of 886 screened articles were
included for full review. The reasons for exclusion were not
detailed. Of the included articles, 1 article qualified for level II
evidence, 42 for level IV evidence and 2 for level V evidence.
The authors conclude that there is substantial level IV evidence with supporting level II evidence that endoscopic sinus
surgery is effective in improving symptoms and QoL in adult
patients with CRS.
In a recent Cochrane review, 3 randomized controlled sinus
surgery studies were included(796). The authors conclude that
FESS, as practiced in the included trials, is not superior to
medical treatment with or without sinus irrigation in patients
with CRS.
66
were considered though the majority were performed endoscopically. Overall there was a high level of satisfaction with
the surgery and clinically significant improvement in the
SNOT-22 scores were demonstrated at 3, 12 and 36 months.
Revision surgery was indicated in 4.1% at 12 months and 10.4%
at 36 months (Level IIc).
In addition to this outcomes research study, 2 recent case
series are also presented to supplement outcome data on CRS
without polyps. In a retrospective analysis, 123 patients with
CRS without nasal polyps who underwent primary FESS with
a minimum 1-year follow-up period were evaluated (793).
Outcome parameters included the Sino-Nasal Outcome Test
(SNOT-20) questionnaire, the Lund-Mackay CT-scoring system, and the need of revision surgery. SNOT-20 scores were
26.5 preoperatively with significant improvement to 5.1 at 6
months and 5.0 at 12 months postoperatively (85% improvement) (level IV). In a case series of 77 patients with CRS without polyps, symptom and endoscopy scores were followed
between 3 and 9 years after FESS (805). Saline douches and nasal
steroids were postoperatively administered as required. After
at least 3 years, more than 90% of the patients reported symptom improvement of 80% or more. Revision surgery was performed in 15%. At the end of the follow up period, 5 patients
(7%) received nasal steroids.
7-4-2-1-2 CRS with polyps
Within the framework of the NHS R&D Health Technology
Assessment Programme, the clinical effectiveness of functional
endoscopic sinus surgery to treat CRS with polyps was
reviewed. The authors screened 444 articles and evaluated 33
articles published between 1978 and 2001 (806). Major reasons for
exclusion were the narrative character of the publication or
less than 50 patients with polyps. The authors reviewed 3 RCT
comparing functional sinus surgery with Caldwell Luc or conventional endonasal procedures (n=240), 3 non-randomized
studies also comparing different surgical modalities (n=2699)
and 27 case series (n=8208). Consistently, patients judged their
symptom improved or greatly improved in 75 to 95 percent
(level IV). The percentage of overall complications was 1.4%
for FESS compared to 0.8% for conventional procedures.
Two thirds (2176) of the 3128 patients participating in the
National Comparative Audit had CRS with nasal polyps (521).
CRS patients with polyps had no longer duration of disease, no
higher previous steroid treatment, nor ratings of their general
health before surgery than CRS patients without polyps.
Irrespective of extent of surgery, clinically significant improvement in the SNOT-22 scores were demonstrated at 3, 12 and
36 months. Polyp patients benefited more from surgery than
the chronic rhinosinusitics without polyps. Revision surgery
was indicated in 3.6% at 12 months and 11.8% at 36 months.
Major complications were rare (Level IIc).
In this context, a case series study of CRS patients with particularly extensive polyposis is worth mentioning (807). Of the 118
patients reviewed, 59 (50%) had asthma, and 93 (79%) had doc-
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67
Conclusion: In the majority of CRS patients, appropriate medical treatment is as effective as surgical treatment. Sinus
surgery should be reserved for patients who do not satisfactorily respond to medical treatment.
7-4-3 Surgical modalities
7-4-3-1 Endonasal versus external approach
Endonasal approaches include surgical procedures performed
through the nostril, irrespective of the extent of surgery and
the kind of visualization of the surgical field. Today, endonasal
procedures are predominantly performed employing endoscopes. The most commonly performed external surgical procedures include the sublabial transfacial Caldwell Luc
approach with or without transantral ethmoidectomy and sphenoidectomy, and transfacial frontoethmoidectomy. In a few
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Supplement 20
recurrence was 8% for FESS compared to 14% for CaldwellLuc approach (806).
McFadden and co-workers evaluated the long term outcome
(up to 11 years) in 25 patients with extensive nasal polyps and
ASA-intolerance. Sixteen patients were operated via an extended endonasal approach and 9 via a Caldwell Luc approach with
radical sphenoethmoidectomy. Of the endonasally operated
patients, 6 underwent a revision surgery via a Caldwell Luc
approach whereas none of the patients who had received a
Caldwell Luc approach initially was reoperated (432).
Conclusion: Long term symptom relief in chronic sinusitis can
be obtained by the endonasal endoscopic and the CaldwellLuc approach, however, results favour the endonasal approach.
The Caldwell-Luc approach carries a higher risk of early postoperative facial swelling and infraorbital nerve irritation.
Comparative studies of endonasal versus external frontoethmoid approaches are currently not available.
7-4-3-2 Conventional endonasal surgery versus functional
endonasal sinus surgery
Conventional sinus surgery is a collective term for surgical
techniques already used before the devlopment of functional
sinus surgery. They include external approaches, maxillary
sinus irrigation, simple (snare) polypectomy, inferior meatal
antrostomy, and radical transnasal spheno-ethmoidectomy
with or without middle turbinate resection. Unlike functional
techniques, conventional sinus procedures do not proceed
along the natural pathways of sinus ventilation and mucociliary
transport revealed by the fundamental work of Messerklinger
(816). Restoring ventilation and mucociliary transport by functional surgery along the natural ostia allows recovery of the
diseased sinus mucosa, which is not resected (817, 818) .
Concurrently with the development of the functional
approach, rigid endoscopes became available, which improved
visualization during endonasal surgery. The evolving concept
of functional endoscopic sinus surgery (FESS) spread worldwide by the efforts of Stammberger and Kennedy (819, 820). In two
studies, a conventional approach was compared with functional
sinus surgery in CRS patients with or without polyps.
In a prospective controlled trial, Arnes and coauthors performed an inferior meatal antrostomy on one side and a middle meatal antrostomy in the opposite nasal cavity in 38
patients with recurrent acute or chronic maxillary sinusitis (821).
The laterality was randomized. After an observation period
ranging between 1 and 5 years, no significant side differences
in symptom scores or radiological findings were observed
(level Ib).
In a randomized controlled trial, 25 patients after functional
endoscopic sinus surgery were compared with 25 after conventional surgery. Conventional surgery included antral puncture,
intranasal ethmoidectomy, and Caldwell-Luc procedures.
Follow up ranged from 15-33 months with a mean of 19
months, at the end of which 76% of the functional group had
69
Conclusion: Functional endoscopic surgery is superior to minimal conventional procedures including polypectomy and antral
irrigations, but superiority to inferior meatal antrostomy or
conventional sphenoethmoidectomy is not yet proven.
parameters was investigated in CRS patients, not differentiating between CRS with and without polyps. In a prospective
trial, 65 CRS patients with and without polyps were randomized to undergo limited endonasal functional surgery
(infundibulectomy) and a more extensive functional procedure
including sphenoethmoidectomy and wide opening of the
frontal recess. Disease extent was similar in both treatment
arms. Outcome parameters included symptom scores,
rhinoscopy scores and nasal saccharin transport time (825). Recall
rates were below 60%. Outcome parameters revealed no relevant differences after 3, 6 and 12 months (level Ib).
Based on the concept that diseased sinus prechambers, not
small sinus ostia, are the cause for chronic sinus inflammation,
minimal invasive sinus surgery (MIST) is advocated by some
authors (826). Basically, sinus ostia are exposed during MIST, but
not enlarged. In a prospective, uncontrolled trial, Catalano and
Roffman followed 85 patients with CRS for a mean 24 months.
Changes in the CSS score served as outcome parameter and
revealed significant improvements similar to FESS studies
(level IV).
Some authors advocate partial resection of the middle
turbinate to expand the surgical approach (827), while others
modify it only in case of abnormalities and leave as much as
possible of the middle turbinate intact as a landmark in case
revision surgery is needed (817). In a retrospective evaluation
including 100 FESS patients, Giacchi and coauthors preserved
the middle turbinate on one side and partially resected it on
the other side (828). The authors observed no side differences in
the outcome parameters studied (level Ib).
In a randomized trial, 1,106 matched CRS patients with and
without polyps, who underwent similar functional endonasal
sinus surgery with (509 patients) or without (597 patients) partial middle turbinate resection (829). Partial middle turbinate
resection was associated with less synechia formation (p<0.05)
and less revision surgeries (p<0.05) than middle turbinate
preservation. Complications particularly caused by partial middle turbinate resection were not observed (level Ib).
In a prospective, randomized trial, uncinectomy was performed
in 295 patients with chronic maxillary sinusitis. In 140 patients,
a large middle meatal window (diameter > 16 mm) was either
unilaterally or bilaterally created, whereas in 140 patients small
middle meatal antral windows (diameter < 6 mm) were produced. In 170 patients, no preoperative CT was available.
Follow up visits were attended by 133 (45%) patients 12 to 38
months after surgery. Outcome parameters included patients
judgment of symptom change (absent, improved, unchanged,
worsened) and various endoscopic findings. Symptom relief,
endoscopy findings and antral window size did not depend on
the surgically created antral window diameter (830).
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their initial surgery and also before the revision surgery than
patients undergoing primary surgery (level IV). McMains and
Kountakis reported a series of 125 patients with a follow up of
at least 2 years after revision endonasal sinus surgery (839).
Outcome parameters included the SNOT-20 and an endoscopy
score. Of these patients, 66 suffered from CRS without nasal
polyps. These patients experienced a significant improvement
of their outcome parameters comparable with the results after
primary surgery reported in other trials (level IV).
7-4-3-4-2 CRS with polyps
McMains and Kountakis also reported the results of 59 CRS
patients with nasal polyps after revision surgery (839). Consistent
with the results of the National Comparative Audit (824) and the
comparative study by Deal and co-workers (793), CRS patients
with polyps had lower SNOT scores preoperatively (less severe
symptoms), more previous surgeries, and a higher CT score
preoperatively than CRS patients without polyps. However, the
improvement of outcome parameters after revision surgery was
significant and comparable with the improvement in CRS
patients without polyps.
Conclusion: Revision endonasal sinus surgery is only indicated, if medical treatment is not sufficiently effective. Substantial
symptomatic improvement is generally observed in both, CRS
with and without polyps, though the improvement is somewhat less than after primary surgery. Complication rates and
particularly the risk of disease recurrence are higher than after
primary surgery. Some patients still suffer from CRS symptoms after several extensive surgical procedures. CT scans frequently show mucosal alterations adjacent to hypersclerotic
bony margins in an extensively operated sinus system. As a
rule, revision surgery is not indicated in these patients.
7-4-3-5 Instruments
In recent years, numerous instruments have been developed
for sinus surgery. Cutting forceps may improve controlled
mucosal resection and help to avoid mucosal tearing. Powered
instruments may facilitate controlled resection, particularly of
large nasal polyps. Continuous suction/irrigation of microdebriders improve visualisation of the surgical field. Moreover,
lasers have been employed for mucosal excisions and bone
ablation. Given the number of devices available, only a few
comparative studies have been published. In these reports,
CRS patients with and without polyps were not differentiated.
7-4-3-6 Cutting instruments
In a prospective double blind trial, 100 consecutive patients
were followed after endoscopic sinus surgery (843). Cutting forceps had been randomly used on one side and non-cutting forceps on the other side. Lateralised symptoms (headache, maxillary pressure, nasal obstruction and secretions) and endoscopic findings (secretion, pus, blood, crusts, oedema, polyps and
adhesions) were evaluated on both sides 1 year postoperative-
71
ly. Both types of instruments gave satisfactory healing situations. No significant difference in the global symptom and
endoscopic score between the 2 types of instruments was
found (level Ib).
Conclusion: Laser assisted endonasal surgery, powered instruments or sharp forceps offer some advantages over conventional instruments but may be associated with some particular
risks. Currently, there is no evidence that they improve sinus
surgery outcomes.
7-5 Influence of age concomitant diseases on sinus surgery outcome
7-5-1 Sinus surgery in the elderly
Previous survey data ranks rhinosinusitis the sixth most common chronic condition of elderly persons, occurring more frequently than cataracts, diabetes and general visual impairment
(849)
. In a case series study, 56 CRS patients between 61 and 80
years old were followed after functional endoscopic sinus
surgery with nasal endoscopy and the SNOT-20 (849). Outcomes
were comparable to reports from younger patient populations,
no severe complication occurred (level IV). In a retrospective
case control study, functional endonasal sinus surgery outcome in 46 CRS patients >65 years were compared with 522
CRS patients who were 18-64 years old (850). In the elder patient
group, complications occurred significantly more frequently
than in the younger patients group. In particular orbital complication were frequently observed in the elder patient group
(level III). Jiang and Su retrospectively compared complication
rates of 171 CRS patients elder than 65 years with 837 adult
patients and 104 patients younger than 16 years. They found
that the geriatric group experienced a disproportionately larger
share of operative complications. Outcomes were similar in all
three groups (851).
Conclusion: CRS is a common condition in the elderly.
Reported sinus surgery outcomes do not differ from a younger
patient population. However, higher surgical complication
rates were found in 2 reports. Moreover, general anaesthesia
bears higher risks and the capacity to recover from a severe
surgical complication such as a CSF leak may be impaired.
7-5-1-1 Asthma
Bronchial asthma is frequently associated with CRS with and
without polyps and may have influence on sinus surgery outcomes. A trend for more severe sinus disease in CRS patients
with concomitant asthma without aspirin intolerance has been
reported by Kennedy (514). Clinically, CRS patients with polyps
and asthma have higher CT-scores, more severe nasal obstruction and hyposmia, and more severe asthma, while CRS
72
Supplement 20
73
Conclusion: Apparently, various confounders not yet sufficiently defined influence the effects of surgical CRS treatment
on concomitant asthma. In studies published in recent years,
predominantly positive effects of surgical CRS treatment on
concomitant asthma severity were reported However, the level
of evidence is low.
7-5-2-1 ASA intolerance
Intolerance to acetylsalicylic acid derived compounds such as
aspirin or other acid NSAIDs frequently manifests as Samters
triad characterized by bronchial asthma, aspirin sensitivity, and
CRS with polyps. The majority of CRS patients with aspirin
intolerance have diffuse, extensive rhinosinusitis (514). In an
early report, poorer outcome in 11 patients with ASA-intolerance out of 120 prospectively followed patients treated with
sinus surgery was observed (514). However, when stratified for
extent of disease, ASA-intolerance did not adversely affect outcome (Level IV). In more recent trials, ASA-intolerance was
rather consistently found to adversely affect sinus surgery outcomes.
In a case series study, 80 patients with ASA-intolerance and
mostly extensive polyps were followed after sinus surgery (868).
Sinus symptoms and asthma severity improved in more than
80% of the patients. Before surgery, more than 30% were
steroid dependent due to asthma severity and less than 10%
after surgery. However, a significant incidence of revision
surgery was observed in this patient group (level IV).
A higher number of repeat operations was also observed in a
retrospective case control trial (869) including 18 patients with
and 22 patients without ASA-intolerance (level IV).
In a retrospective chart review, 17 patients who underwent ESS
with nasal polyps and steroid-dependent asthma with or without aspirin sensitivity and a minimum of 1 year postoperative
follow-up were evaluated (870). Nine patients were ASA sensitive, and eight patients were ASA tolerant. The postoperative
Lund-Mackay scores (p<0.001), the forced expiratory volume
at 1 second (FEV1, p<0.05), and systemic steroid consumption
(p<0.05) improved significantly in the 17 patients. Unlike ASA
tolerant patients, the 9 ASA sensitive patients did not have a
significant improvement in postoperative FEV1 and sinonasal
symptoms (level IV).
In a multivariate analysis of various outcome predictors,
119 adult patients with CRS were prospectively followed-up for
1.4 +/- 0.35 years after sinus surgery. ASA intolerance was the
only concomitant condition significantly worsening the outcome (519).
Conclusion: CRS patients with ASA-intolerance tend to suffer
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75
group was 2.7. The authors report improved pulmonary function, sinus symptoms, and exercise tolerance 3 months post
surgery, however, polyps recurred in all patients within 18
months (Level IV).
Rowe-Jones and Mackay performed endoscopic sinus surgery
on 46 cystic fibrosis patients with chronic, polypoid rhinosinusitis (891). Their mean age at first surgery was 237.5 years.
Follow-up ranged from 1 month to 6 years (mean, 28.2
months). Overall, 50% of the patients suffered either recurrence of preoperative severity or had to undergo second endoscopic sinus procedure (level IV).
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77
minor complications
major complications
orbital
orbital emphysema
ecchymosis of the eyelid
orbital hematoma
loss of visual acuity/blindness
diplopia
enophthalmia
nasolacrimal duct damage
intracranial
CSF leak
pneumcephalus (Tension )
encephalocoele
brain abcess
meningitis
intracranial (subarachnoid) bleeding
direct brain trauma
bleeding
Table 7-16. Epidemiology of complications following paranasal surgery, using non-endoscopic techniques
author/year
orbita
intracranial
bleeding
others
minor
565
16
284
87
123
no numbers
Sogg, 1989
(917)
146
1163
25
600
3000
288
(919)
78
Supplement 20
Table 7-17. Epidemiology of complications following paranasal surgery, using endoscopic techniques (adapted from (923))
author/year
orbital
intracranial*
bleeding
others
minor
100
14
170
100
10
500
22
118
28
500
10
no numbers
210
16
593
38
589
20
15
no numbers
120
1165
94
200
16
(1105)
386
no numbers
551
no numbers
650
no numbers
337
34
(934)
(800)
230
10
553
36
325
30
1172
10
10
(937)
no numbers
-
no numbers
415
12
12
56
1500
no numbers
Marks, 1999
393
(941)
(943)
3128
14005
3
7
5
2
60
(0,40%)
65
(0,50%)
84
(0,60%)
22
-
14
(0,01%)
207
506
(3,60%)
overall major complication rate of 0.03% (12 major orbital complications and 22 intracranial complications in 10,000 FESS
operations).
major
complications
no of
deaths
endoscopic ethmoidectomy
0.41%
0.36%
23
external ethmoidectomy
0.52%
transantral ethmoidecthomy
0.18%
79
RP
FP
An
Al
As
NP
questionnaire, endoscopy
182
12
u1
no
no
no
Gliklich
108
Kennedy (514)
120
Kim (946)
endoscopy score
98
Marks
(486)
PO
AI
PS
-
no
no
no
no
no
u4
yes
no
no
no
no
12
no
no
no
no
yes
no
improvement score
93
12
no
yes
no
no
no
no
Marks (801)
endoscopy score
93
12
no
no
yes
no
no
no
Marks (801)
revision needed
93
12
yes
no
no
no
no
yes
Smith (803)
endoscopy score
119
12
no
yes6
0.09
no
no
no
yes7
Smith
no
yes
no
no
no
yes10
0.09
no
no
(801)
RSDI
119
12
Smith (803)
CSS
119
12
Wang (802)
CSS
230
Wang (802)
endoscopy score
230
(803)
no
no
yes
no
no
0.09
no
yes
yes
yes
yes
RP: Recall/participants; FP: Minimum follow up; An: Analysis; A: Age; S: Sex; PO: Pre-operative score; E: Extent; Al: Allergy; As: Asthma;
a
NP: Polyps; AI: Aspirin intolerance; PS: Previous surgery
1: univariate, 2: multivariate, 3: high preoperative CSS score was associated with worse outcome, 4: stratified for disease severity, 5: less symptomatic
improvement in females (p=0.008), 6: worse scores associated with more improvement, 7: associated with less improvement, 8: worse scores associated with more improvement, 9: ssociated with less improvement, 10: worse scores associated with more improvement
Sinus surgery is well established and there are several techniques used to adequately treat the pathology. Nevertheless,
the risk of minor or major complications exists and has to be
balanced with the expected result of operative or conservative
treatment. The learning curve of less-experienced operators
has to be considered, as well as the complexity of the individual case.
A preoperative CT-scan is nowadays standard in the preoperative assessment and especially important in revision surgery
where image guidance may have a role.
80
Supplement 20
country
age
pathology
pts
total % of
complications
orbital
intracranial
osseous
soft tissue
Mortimore, 1999
South Africa
adults
acute pansinusitis
87
72.4% (63/87)
Nigeria
adults
acute/chronic
pansinusitis
90
37% (33/90)
41%
5%
32%
18%
Germany
adults/
children
acute pansinusitis
36
75% (27/36)
58% (20+1/36)
11% (3+1/36)
Russia
adults
rhinosinusitis
0.8%
0.01%
USA
adults
rhinosinusitis
176
8.5% (15/176)
USA
adults
acute/chronic
rhinosinusitis
649
3.7% (24/649)
USA
children
rhinosinusitis
443
3%
(14/443)
(954)
Ogunleye, 2001
(955)
Eufinger, 2001
(956)
Kuranov, 2001
(957)
Gallagher, 1998
(958)
Clayman, 1991
(959)
8.4%
(3/36)
81
swelling, exophthalmos, and impaired extra-ocular eye movements (966). Periorbital or orbital cellulitis may result from direct
or vascular spread of the sinus infection. As the spread of sinus
infection through the orbit follows a well-described pattern,
the initial manifestations are oedema and erythema of the
medial aspects of the eyelid. Spread of infection from the maxillary or frontal sinus produces swelling of the lower or upper
eyelid, respectively (964).
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Supplement 20
(958)
number
complications
mortality/further defects
176 patients
mortality 7%
morbidity 13%
16 patients
6 meningitis
6 frontal lobe abscess
5 epidural abscess
4 subdural abscess
2 cavernous sinus thrombophlebitis
mortality 40%
surviving patients often have
neurological disability
18 patients
(mean age 12 y)
7 epidural abscess
6 subdural abscess
2 intracerebral abscess
2 meningitis
1 cavernous sinus thrombophlebitis
25 patients
(mean age 13 y)
13 epidural abscess
9 subdural abscess
6 meningitis
2 encephalitis
2 intracerebral abscess
2 cavernous sinus trhomboplebitis
mortality 4 %
12 patients
(mean age 14 y)
mortality 8%
morbidity 16 %
8 patients
(mean age 12 y)
1 cerebral abscess
1 cerebral infarct
3 frontal bone osteomyelitis
4 subdural abscess
4 subdural abscess
no mortality
essential when there are some degrees of soft tissues involvement such as in cavernous sinus thrombosis (958). Moreover, if
meningitis is suspected, a lumbar puncture could be useful (958)
once an abscess has been excluded.
High dose long term i.v. antibiotic therapy followed by craniotomy and surgical drainage are usually required for successful treatment (351). Pathogens most commonly involved in the
pathogenesis of endocranial complications are Streptococcus
and Staphylococcus species and anaerobes (973).
83
author, year
mucocoele or mucopyocoele
septicaemia
84
Supplement 20
adults
Coagulase negative
staphylococci
30%
35%
Staphylococcus aureus
20%
8%
Haemophilus influenzae
40%
0%
Moraxella catarrhalis
24%
0%
Commensal microflora
Streptococcus pneumoniae
50%
26%
Corynebacterium species
52%
23%
Streptococcus viridans
30%
4%
Immunity
immature:
defective response
to polysaccharide
antigens
(IgG2, IgA)
mature, except
in a subset
History
self-limited in
time (improves
after the age of 6-8
years)
no history of
spontaneous
improvement
after certain age
Histology
mainly
eosinophils
Endoscopy
polyps frequently
present
CT-scan
younger child
more diffuse
sinusitis, involving
all sinus
sphenoid and
posterior sinus
less often
involved
9-2 Anatomy
In the newborn, the maxillary sinus extends to a depth of
about 7 mm, is 3 mm wide and 7 mm high (980). In the newborn,
two to three ethmoid cells are found bilaterally, and by the age
of four the ethmoid labyrinth has formed. The sphenoid sinuses are also present in the neonate. Each sphenoid sinus is 4
mm wide and 2 mm high. At birth the frontal sinuses are not
85
complicated by ARS (986). The time course (i.e. clinical symptoms) of viral to bacterial rhinosinusitis is the same as in
adults.
The most common bacterial species isolated from the maxillary sinuses of patients with ARS are Streptococcus pneumoniae,
Haemophilus influenzae, and Moraxella catarrhalis, the latter
being more common in children (45, 46).
9-6 Investigations
rhinorrhoea (71 to 80 %)
all forms
cough (50 to 80 %)
all forms
fever (50 to 60 %)
acute
pain (29 to 33 %)
acute
chronic
chronic
chronic
9-6-1 Microbiology
Microbiological assessment is usually not necessary in children
with uncomplicated acute or chronic rhinosinusitis.
Indication for microbiology are: (995)
1. severe illness or toxic child;
2. acute illness in a child not improving with medical therapy
within 48-72 hours;
3. an immuocompromised host;
4. the presence of suppurative (intra-orbital, intracranial)
complications (orbital cellulitis excepted).
Quantification of bacterial growth can also help in distinguishing contamination from real infection, and isolates should be
considered positive when a type of bacteria is present in a
quantity of at least 10,000 colonies/ml (990).
9-6-2 Imaging
Imaging is not necessary to confirm the diagnosis of rhinosinusitis in children. The increase in thickness of both the soft
tissue and the bony vault of the palate in children under 10
years of age limits the usefulness of transillumination and
ultrasonography in the younger age group (505).
Plain X-rays are insensitive with limited usefulness for diagnosis or to guide surgery and correlate very poorly with CT scans.
The marginal benefits are insufficient to justify the exposure to
radiation (220).
CT scanning remains the imaging methodology of choice,
because of its ability to resolve both bone and soft tissue, with
good visualisation of the ostiomeatal complex. The indications
for CT scanning in a child are the same as those given previously for a microbiology specimen with one extra indication
which is if surgery is being considered after failure of medical
therapy. The high incidence of asymptomatic children with CT
scan abnormalities (996) must be remembered plus the fact that
such children do not require treatment. (997).
86
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87
88
Supplement 20
89
is a reasonable alternative to continuous medical treatment. Optimal management includes a 2-6 weeks of adequate antibiotics (IV or oral) with treatment of concomitant disease.
90
Supplement 20
which host factors like anatomical, local defense and immunologic factors, act in synergy with microbial and environmental
factors in the development and chronicity of the disorder.
Histopathologic features of CRS and asthma largely overlap.
Heterogeneous eosinophilic inflammation and features of airway remodeling like epithelial shedding and basement membrane thickening, are found in the mucosa of CRS and asthma
patients (1061). Cytokine patterns in sinus tissue of CRS highly
resemble those of bronchial tissue in asthma (30), explaining the
presence of eosinophils in both conditions. Therefore,
eosinophil degranulation proteins may cause damage to the
surrounding structures and induce symptoms at their location
in the airway. Finally, lavages from CRS patients show that
eosinophils were the dominant cell type in both nasal and
broncho-alveolar lavages in the subgroup of patients with CRS
with asthma (266). Beside the similarities in pathophysiology,
sinusitis has been aetiologically linked to bronchial asthma,
and vice versa. As is the case in allergic airway inflammation,
sinusitis and asthma can affect and amplify each other via the
systemic route, involving interleukin (IL)-5 and the bone marrow. In both CRS and allergic asthma, similar pro-inflammatory markers are found in the blood. Recently, nasal application
of Staphylococcus aureus enterotoxin B has been shown to
aggravate the allergen-induced bronchial eosinophilia in a
mouse model (422). Here, mucosal contact with enterotoxin B
induced the systemic release of the typical T helper 2 cytokines
IL-4, IL-5 and IL-13, leading to aggravation of experimental
asthma. However, the interaction between both rhinosinusitis
and asthma in not always clinically present, as Ragab et al. (266)
found no correlation between rhinosinusitis and asthma severity. However, patients with asthma showed more CT scan
abnormalities than non-asthmatic patients (1063), and CT scan
abnormalities in severe asthmatic patients correlated with sputum eosinophilia and pulmonary function (1062).
Endoscopic sinus surgery (ESS) for CRS aims at alleviating
sinonasal symptoms but also improves bronchial symptoms
and reduces medication use for bronchial asthma (861, 863, 1064, 1065).
After a mean follow-up period of 6.5 years, 90% of asthmatic
patients reported their asthma was better than it had been
before the ESS, with a reduction of the number of asthma
attacks and medication use for asthma (1060). Also in children
with chronic rhinosinusitis and asthma, sinus surgery improves
the clinical course of asthma, reflected by a reduced number of
asthma hospitalizations and schooldays missed (1066). Lung function in asthma patients with CRS was reported to benefit from
ESS by some authors (853, 861), but denied by others (863, 1064, 1066). Of
note, not all studies show beneficial effects of ESS on asthma
(862)
. The reason for the inconsistency in study results between
91
Until recently, no well-conducted clinical trials have been performed showing beneficial effects of medical therapy for CRS
on bronchial asthma. Ragab et al. (864) published the first randomized prospective study of surgical compared to medical
therapy of 43 patients with CRS with/without NP and asthma.
Medical therapy consisted of a 12 weeks course of erythromycin, alkaline nasal douches and intranasal corticosteroid
preparation, followed by intranasal corticosteroid preparation
tailored to the patients' clinical course. The surgical treatment
group underwent ESS followed by a 2 week course of erythromycin, alkaline nasal douches and intranasal corticosteroid
preparation, 3 months of alkaline nasal douches and intranasal
corticosteroid, followed by intranasal corticosteroid preparation tailored to the patients' clinical course. Both medical as
well as surgical treatment regimens for CRS were associated
with subjective and objective improvements in asthma state.
Interestingly, improvement in upper airway symptoms correlated with improvement in asthma symptoms and control.
10-3 Asthma and Chronic Rhinosinusitis with NP
Seven percent of asthma patients have nasal polyp (174) and in
non-atopic asthma and late onset asthma, polyps are diagnosed
more frequently (10-15%). Aspirin-induced asthma is a distinct
Increased nasal colonization by Staphylococcus aureus and presence of specific IgE directed against Staphylococcus aureus
enterotoxins was found in NP patients (415). Interestingly, rates of
colonization and IgE presence in NP tissue were increased in
subjects with NP and co-morbid asthma or aspirin sensitivity. By
their superantigenic activity, enterotoxins may activate inflammatory cells in an antigen-non-specific way. Indeed, nasal application of Staphylococcus aureus enterotoxin B is capable of
aggravating experimental allergic asthma (422). Besides bacterial
enterotoxins, Ponikau et al. report on the potentially important
role of fungi, especially Alternaria, in the generation of chronic
sinus disease with NP (1070). By their capacity to induce eosinophil
degranulation (1071), Alternaria may contribute to the inflammatory spectrum of CRS with/without NP and asthma.
No well-conducted trials on the effects of medical therapy for
NP on asthma have been conducted so far. Therefore, welldesigned trials on nasal corticosteroids, oral antibiotics, vaccination therapy or anti-leukotriene treatment in patients with
NP and asthma are warranted. After ESS for NP in patients
with concomitant asthma, a significant improvement in lung
function and a reduction of systemic steroid use was noted,
whereas this was not the case in aspirin intolerant asthma
patients (1068). In a small series of patients with NP, endoscopic
sinus surgery did not affect the asthma state (589). However,
nasal breathing and quality of life improved in most patients.
10-4 COPD and rhinosinusitis
Up to 88 % of patients with COPD presenting at an academic
unit of respiratory disease may experience nasal symptoms,
most commonly rhinorrhoea (1072). Nasal symptoms in COPD
patients correspond well with an overall impairment of the
quality of life (1072). So far, no further information is available on
the nasobronchial interaction in COPD patients.
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Supplement 20
93
It should be noted that in this last study, the patient population evaluated were generated through visits to an otorhinolaryngologist. Therefore, this patient population had already
failed initial therapy by primary care givers and possibly by
other otolaryngologists. The therapeutic interventions by the
specialist are therefore likely to be biased toward more aggressive and thus more expensive therapy.
The cost burden of absenteeism is enormous, and yet it is only
the beginning. The general health status of patients with CRS
is poor relative to the normal US population (588) . This
decreased quality of life not only leads to absenteeism, but also
contributes to the idea of presenteeism or decreased productivity when at work. Ray et al estimated by the 1994 National
Health Interview Survey, that missed worked days due to rhinosinusitis was 12.5 million and restricted activity days was
58.7 million days (3). Economic loss due to presenteeism cannot
be easily quantified, but surely increases the cost burden of the
disease.
94
Supplement 20
Table 12-1 Criteria for studies conducted in primary and secondary care
criteria
primary care
secondary care
imaging
plain x-ray
CT (scoring eg Lund-Mackay 0-24)
+
-
medication use
smoking history
safety assessments
ethics approval
drop-out analysis
95
therapy
level
grade of
recommendation
relevance
oral antibiotic
Ia
topical corticosteroid
Ib
yes
Ib
yes
oral corticosteroid
Ib
oral antihistamine
Ib
nasal douche
Ib (-)#
no
topical corticosteroid
IV
yes
Ib
yes
level
grade of recommendation
relevance
oral antibiotic
Ia
decongestant
Ib (-)#
yes, as symtomatic
relief
mucolytics
none
no
no
topical decongestant
III (-)
no
phytotherapy
Ib
no
saline douching
IV
yes
Table 13-3 Treatment evidence and recommendations for adults with chronic rhinosinusitis without nasal polyps *
therapy
level
grade of recommendation
relevance
Ib (-)
no
Ib (-)
yes
Antibiotics topical
III
no
steroid topical
Ib (-)
yes
steroid oral
no data
no
Ib (-)
yes
no data
no
mucolytics
III
no
antimycotics systemic
Ib (-)#
no
antimycotics topical
Ib (-)#
no
no data
no
no data
no
bacterial lysates
Ib (-)
no
immunomodulators
Ib (-)#
no
phytotherapy
Ib (-)#
no
anti-leukotrienes
III
no
* tSome of these studies also included patients with CRS with nasal polyps
* Acute exacerbations of CRS should be treated like acute rhinosinusitis
# : Ib (-) study with a negative outcome
96
Supplement 20
level
grade of
recommendation
relevance
no data
yes, immediately
postoperative,
if pus was seen
during operation
oral antibiotic
long term ~ 12 weeks
no data
yes
topical antibiotics
no data
no
topical steroid
Ib (one
+, one -)
yes
oral steroid
no data
nasal douche
no data
available
yes
level
grade of recommendation
relevance
oral antibiotic
Ia
topical corticosteroid
IV
yes
saline douching
III
yes
III
yes
* Some of these studies also included patients with CRS with nasal polyps
Table 13-5. Treatment evidence and recommendations for adults with chronic rhinosinusitis with nasal polyps *
therapy
level
grade of recommendation
relevance
no data
no
Ib
topical antibiotics
no data
no
topical steroids
Ib
yes
oral steroids
Ib
yes
nasal douche
no
mucolytics
no data
no
antimycotics systemic
Ib (-)#
no
antimycotics topical
Ib (-)#
no
Ib (1)#
no, in allergy
capsaicin
II
no
II
no
immunomodulators
no data
no
phytotherapy
no data
no
anti leukotrienes
III
no
* Some of these studies also included patients with CRS without nasal polyps
# : Ib (-) study with a negative outcome
Table 13-6. Treatment evidence and recommendations postoperative treatment in adults with chronic rhinosinusitis with nasal polyps*
Therapy
Level
Grade of recommendation
Relevance
oral antibiotics
short term < 2 weeks
no data
immediately post-operative,
if pus was seen during operation
oral antibiotics
long term > 12 weeks
Ib
yes
yes
Ib
yes
oral steroids
no data
yes
nasal douche
no data
yes
* Some of these studies also included patients with CRS without nasal polyps .
T
13-2 Introduction
Since the preparation of the first EP3OS document an increasing amount of evidence on the pathophysiology, diagnosis and
treatment has been published (figure1-1).
However, in compiling the tables on the various forms of therapy, it may be that despite well powered level Ib trials, no significant benefit has been demonstrated. Equally results may be
equivocal or apparently positive results are undermined by the
small number of trials conducted and/or the small number of
participants in the trial(s). In these cases, after detailed discussion, the EPOS group decided in most cases, that there was no
evidence at present to recommend use of the treatment in
question. Alternatively for some treatments no trials have been
conducted, even though the treatment is commonly used in
which case a pragmatic approach has been adopted in the recommendations.
97
98
Supplement 20
Treatment
Treatment evidence and recommendations for acute rhinosinusitis
see Table 13-1.
Initial treatment depending on the severity of the disease:
See figure 13-1.
mild: start with symptomatic relief (decongestants, saline,
analgesics);
moderate: additional topical steroids
severe: additional antbibiotics and topical steroids
Figure 13-1. Treatment scheme for primary care for adults with acute rhinosinusitis
99
Signs
nasal examination (swelling, redness, pus);
oral examination: posterior discharge;
exclude dental infection.
ENT-examination including nasal endoscopy.
Not recommended: plain x-ray.
CT-Scan is also not recommended unless additional problems
such as:
very severe diseases,
immunocompromised patients;
signs of complications.
Figure 13-2. Treatment scheme for ENT specialists for adults with acute rhinosinusitis
100
Supplement 20
Figure 13-3 Treatment scheme for Chronic Rhinosinusitis with or without nasal polyps for primary care and non-ENT specialists
101
Signs
ENT examination, endoscopy;
review primary care physicians diagnosis and treatment;
questionnaire for allergy and if positive, allergy testing if it
has not already been done.
Diagnosis
Symptoms present longer than 12 weeks
Two or more symptoms one of which should be either nasal
blockage/obstruction/congestion or nasal discharge
(anterior/posterior nasal drip):
facial pain/pressure,
reduction or loss of smell;
Figure 13-4. Treatment scheme for ENT-Specialists for adults with CRS without nasal polyps
102
Supplement 20
Signs
ENT examination, endoscopy;
review primary care physicians diagnosis and treatment;
questionnaire for allergy and if positive, allergy testing if
not already done.
Severity of the symptoms
(following the VAS score for the total severity) mild/moderate/severe.
Figure 13-5. Treatment scheme for ENT-Specialists for adults with CRS with nasal polyps
103
Symptoms persistent
or increasing after 5 days
Common cold
Moderate
Symptomatic relief
Asthma
chronic bronchitis
No
Severe*
Non-toxic
Oral antibiotics
Hospitalisation
IV antibiotics
Hospitalisation
Nasal endoscopy
Culture
Imaging
IV antibiotics
and/or surgery
Yes
No effect in 48 h
Symptomatic relief
At any point
Immediate referral/hospitalisation
Periorbital oedema
Displaced globe
Double vision
Ophthalmoplegia
Reduced visual acuity
Severe unilateral or
bilateral frontal headache
Frontal swelling
Signs of meningitis or
focal neurologic signs
Oral amoxicillin
can be considered
Hospitalisation
*
fever > 38C
severe pain
104
Supplement 20
105
106
Supplement 20
107
Rhinorrhoea: any discharge from the nose. May run from the
front of the nose (anterior) or into the back (posterior or postnasal discharge)
Rhinosinusitis: inflammation of the nose and paranasal sinuses
Simple polypectomy: surgical removal of polyps from the nasal
cavity without additional surgery on the paranasal sinuses
Treatment:
short term treatment: usually 2 weeks or less
long-term treatment: usually 12 weeks or longer
108
Supplement 20
SF-36: www.sf-36.org
Euro-QOL: www.euroqol.org
SF-12: derived from the SF-36: www.sf-36.org
Quality of Well-Being Scale: jharvey@ucsd.edu
Glasgow Benefit Inventory:
www.ihr.mrc.ac.uk/scottish/products/ghsq.php
Mc-Gill pain questionnaire: Ronald Melzack: Department
of Psychology, McGill University, 1205 Dr. Penfield
Avenue, Montreal, Que. H3A 1B1, , Canada
109
Year
Test name
Test-Time
Country
Sample size
Cain
1983
1988
1989
CCCRC
35 min
USA
>700
Doty et al (1084)
1984
(a,b)
1985
UPSIT
15 min
USA
>3000
Wright (1085)
1987
Odourant
Confusion
15 min
USA
Kurtz et al (1086)
2001
Matrix
(OCM)
Hendriks (1087)
1988
GITU
Netherlands
Corwin (1088)
1989
1992
YN-OIT
USA
Takagi (1089)
1989
T&T
Olfactometer
Japan
Anderson et al
1992
SDOIT
1994
(1081-1083)
Test retest
Subject differences
Method
Age, gender,
diseases, olfactory
disorders.
1/ Threshold. Nbutanol.
2AFC 4-correct-in-arow method. Separate
nostrils. Odours in
squeeze bottles
2/Identification. 10
odours (score on &+1).
Forced choice from
20 (or 16) descriptors.
Odours in jars. Separate nostrils. Feedback.
Identification of 40
encapsuated odours.
4AFC. Scratch-andsniff- technique
480
Disease.
Identification of 10
odours each presented
once (100 stimuli
or 121 if a blank
is added). Forced
choice from list of 10
names. Pattern of
odorant identification
and misidentification.
221
Identification of 18
or 36 odours. Forced
choice either from 4
alternatives or from a
list of 24 for 18 odours
to identify.
Everyday life odours.
Odours in jars.
Age, disease
Based on 20 UPSIT
odours. Yes or no
matching of a descriptor to a proposed
odour.
>1000
Olfactory disorders.
USA
Young
children
Age.
Identification of
10 odours. Forced
choice using an array
of 20 visual stimuli.
Odours in jars.
France
84
Olfactory disorder,
disease.
Odours in bottles.
1/Threshold to 5
odorants.
2/Identification of 6
odorants.
Odours in bottles.
USA
Europe
Asia
>3000
Identification of 12
encapsulated odours.
4AFC. Scratch and
sniff technique.
r=0.981
(1090)
1995
1996
CC-SIT
MOD-SIT
5 min
r=0.71
110
Supplement 20
Author(s)
Year
Kobal et al (1093)
1996
Robson et al (1094)
1996
Hummel et al (1095)
Kobal et al (1096)
1997
Test name
Test-Time
Country
Sample size
Test retest
Subject differences
Method
5 min
Germany
152
r=0.73
Gender, olfactory
disorder, age.
Identification of
7 odours in pens.
Forced choice from 4
alternatives.
Combined
olfactory
test
UK and New
Zealand
227
Olfactory disorder.
SniffinSticks
Germany,
>1000
Age, olfactory
disorder.
Odours in pens.
2000
Switzerland,
Austria,
Australia,
Italy,
USA
Davidson and
Murphy (1097)
1997
AST
Ahlskog et al (1098)
1998
CA-UPSIT
Nordin (1099)
1998
SOIT
Kremer et al (1100)
1998
McCaffrey et
al (1101)
2000
PST
Kobal et al (1102)
2001
Random
test
Hummel et al (1103)
2001
Four-minute odour
identification test
Cardesin et al.,
2006
Barcelona
Smell
Test - 24
(BAST-24)
(1104)
r=0.72
5 min
USA
100
Olfactory disorder.
Guamanian
Chamorro
57
Neuro-degnerative
disease.
Educational level.
Identification of 20
encapsulated odours.
4AFC. Scratch-andsniff technique.
15 min
Sweden
Finland
>600
Identification of 16
odours in bottles.
4AFC
4 min
Germany
Netherlands
>200
Hyposmia.
USA
40
Identification of 3
encapsulated odours.
4AFC. Scratch-andsniff technique.
10 min
Germany
273
r=0.71
Gender, olfactory
disorder.
Labelling of 16
concentrations of two
odorants randomly
presented.
4 min
Germany
1,012
r=0.78
Age, olfactory
disorder.
Identification of
12 odours. 4AFC.
Odours in pens.
Spanish
120
r=0.79
24 odours scoring
smell detection, identification, and forced
choice
111
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